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Policy Research Working Paper 7348

Long-Run Effects of Temporary Incentives on Medical Care Productivity

Pablo CelhayPaul Gertler

Paula GiovagnoliChristel Vermeersch

Health Nutrition and Population Global Practice GroupJune 2015

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Abstract

The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the series is to get the findings out quickly, even if the presentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations, or those of the Executive Directors of the World Bank or the governments they represent.

Policy Research Working Paper 7348

This paper is a product of the Health Nutrition and Population Global Practice Group. It is part of a larger effort by the World Bank to provide open access to its research and make a contribution to development policy discussions around the world. Policy Research Working Papers are also posted on the Web at http://econ.worldbank.org. The authors may be contacted at [email protected].

The adoption of new clinical practice patterns by medical care providers is often challenging, even when the patterns are believed to be efficacious and profitable. This paper uses a randomized field experiment to examine the effects of temporary financial incentives paid to medical care clinics for the initiation of prenatal care in the first trimester of pregnancy. The rate of early initiation of prenatal care was 34 percent higher in the treatment group than in the control

group while the incentives were being paid, and this effect persisted at least 15 months and likely 24 months or more after the incentives ended. These results are consistent with a model where the incentives enable providers to address the fixed costs of overcoming organizational inertia in innova-tion, and suggest that temporary incentives may be effective at motivating improvements in long-run provider perfor-mance at a substantially lower cost than permanent incentives.

Long‐RunEffectsofTemporaryIncentivesonMedicalCareProductivity

PabloCelhayPaulGertler

PaulaGiovagnoliChristelVermeersch

JELClassification:I12,I13,I15,I18Keywords:Keywords:Pay‐for‐performance, results‐based financing,providerperformance,birthoutcomes,impactevaluation,maternalandchildhealth,organizationalinertia,temporaryincentivesAuthorAffiliation:PabloCelhay([email protected])isaPh.D.candidateattheUniversityofChicago.PaulGertler([email protected])istheLiKaShingProfessorattheUniversityofCalifornia,Berkeley.PaulaGiovagnoli([email protected])isanEconomistwiththeWorldBank.ChristelVermeersch([email protected])isaSeniorEconomistattheWorldBank.

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Acknowledgements:Theexperimentdescribedinthispaperwasdevelopedundertheleadershipof Martin Sabignoso, National Coordinator of Plan Nacer and Humberto Silva, National Head ofStrategicPlanningofPlanNacer,MinistryofHealth,Argentina.Togetherwiththenationalteam,LuisLopez Torres and Bettina Petrella from the Misiones Office of Plan Nacer oversaw theimplementation of the pilot, facilitated access to provincial data, supported the authors ininterpretingdatasetsandtheprovinciallegalframeworkandincarryingoutthein‐depthinterviews.Fernando Bazán Torres, Ramiro Flores Cruz, Santiago Garriga, Alfredo Palacios, Rafael Ramirez,SilvestreRiosCenteno,GabrielaMoreno,andAdamRossprovidedexcellentassistanceandprojectmanagementsupport.AlvaroS.Ocariz,JavierMinskyandthestaffoftheInformationTechnologyunitat Central Implementation Unit (UEC) at the Ministry of Health provided valuable support inidentifyingsourcesofdata.TheauthorsacknowledgethecontributionsofSebastianMartinez,LuisPerezCampoy,VaninaCamporealeandDanielaRomerointheinitialdesignofthepilot.Theauthorsalso thankNedAugenblick,DanBlack,NickBloom,MeganBusse, StefanoDellaVigna,DamiendeWalque,EmanuelaGalasso, JeffGrogger,PetraVergeer, aswell asparticipants in seminars atUCBerkeley, Northwestern University and Chicago University for helpful comments. The authorsgratefullyacknowledgefinancialsupportfromtheHealthResultsInnovationTrustFund(HRITF)andtheStrategicImpactEvaluationFund(SIEF)oftheWorldBank.Theauthorsdeclarethattheyhavenofinancialormaterialinterestsintheresultsofthispaper.

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1 INTRODUCTION

Successfulorganizationsareabletoefficientlyandreliablyproducehighqualityproductsthrough

theuseofreproducibleandstableroutines.1Routinesshapetheproductionprocessbydefiningeach

person’sroleandtheirpatternsofaction,andbycoordinatingthetasksperformedbythedifferent

teammembers.2 They can be thought of as organizational habits that reduce the complexity of

decision‐making,facilitatecoordinationacrossteammembers,andspeedproduction.However,once

established, routines are costly to change. The cost of adjustment includes the time andmoney

neededtoretoolroutines,anadjustmentperiodinwhichproductionislessreliablewhilethenew

routinesarebeinglearned,andpossiblypsychologicalresistancetochange.Asaresult,organizations

tendtoberesistanttoadoptingstructuralchangesthatarethoughttobeproductiveandprofitable

(HannanandFreeman1984;CarrollandHannan2000).Whileorganizationalroutinesarenecessary

forefficientandreliableproduction,theycanresultinorganizationalinertiatoinnovation.

Nowhereareorganizationalroutinesmoreimportantthanintheproductionofmedicalcare

services(Hoff2014).Medicalcareentailscoordinatingalarge,complexsetoftaskssuchasdeciding

what information to collect from the patient, assessing social and medical risks, deciding what

diagnostic tests to prescribe, interpreting symptoms and test results, and prescribing and

implementing treatments.3 Typically, a teamcoordinatedbyaphysician implements these tasks.

Nursesoftentakemedicalandsocialhistories,conductpreliminaryphysicalexams,andadminister

injections.Laboratorytechniciansanalyzebloodandurine.Pharmacistsdispensedrugsandmonitor

negative drug interactions. Physical and occupational therapists provide rehabilitation services.

Community health‐workers provide outreach, promotion and preventive services, and follow‐up

care to patients. Clinics establish practice routines that are consistent with their training and

experiencetostandardizeandcoordinatecare.

There is substantialevidenceoforganizational inertia inmedical careas indicatedby the

remarkablylowlevelofcompliancewithClinicalPracticeGuidelines(CPGs)worldwide(Figure1).

1OrganizationalroutinehasbeenstudiedextensivelysincepopularizedbyNelsonandWinter(1982).Ina

review of the literature Becker (2004) defines routines as “recurrent interaction patterns” within anorganization,oras“establishedrules,orstandardoperatingprocedures”.

2 Often relationships between team members and management are enforced by informal relationalcontracts(GibbonsandHenderson2012and2013).

3 Complex production technologies with sophisticated routines such as medical care require strongmanagementtobeefficientandproductive. Bloometal. (2014)provideevidencethatbettermanagementincreasespublichospitalproductivity.

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CPGsdefinemedicalcareproductionpossibilityfrontiersinthattheyprescribetheclinicalcontent

ofcarethatmaximizesthelikelihoodofsuccessfulhealthoutcomesbasedonmedicalscience,clinical

trials,andpractitionerconsensus.LocalCPGsareregularlyupdatedandserveasthebasisoftraining

inmedicalschoolsandpractitionerrefreshercourses.WhilethelackofcompliancewithCPGsmay

inpartreflectalackofknowledge,evidenceshowsthatpractitionersoftenprovideastandardofcare

wellbelowtheirlevelofknowledgeofCPGs.4Inasystematicreviewoftheliteratureonreasonsfor

non‐complianceofCPGs,Cabanaetal. (1999)report thatresistancetochangingexistingpractice

patternsisoneofthemostimportantbarrierstoCPGadherence.Forexample,GrolandGrimshaw

(2003)surveyednursesanddoctorsintheUKabouttheadoptionofnewhandhygieneguidelines.

Forty‐ninepercentrespondedthatresistancetochangingoldroutineswasanobstacletocomplying

withnewguidelines.5

Changingdeep‐rootedhabitsishardandevensmallcostsofadjustmentmayinhibitchanges

in favor of maintaining the status quo, (DellaVigna 2009; Thaler and Sunstein 2009).6 In these

circumstances,temporaryincentivesmayspeedadoptionbyhelpingtocompensateprovidersfor

theinitialfixedcostsofchangingtheirpracticepatternroutines.Thisamountstopayingprovidersa

time‐limitedperunitincentivefortheprovisionofacomponentoftheCPGsforaspecificcondition.7

Theuseoftemporaryincentivestoovercomeorganizationalinertiainfirmsissimilarinspirit

to theuseof temporary incentives to change individual and consumerbehavior. Firmsoftenuse

temporarypricediscounts,suchassalesandcoupons,tomarkettheirproducts(BlattbergandNeslin

1990;KirmaniandRao2000;andDupas2014).Discountsencourageindividualstopurchasegoods

thattheyarenotinthehabitofbuyingwhichinturnallowthemtoupdatetheirbeliefsaboutthe

product’sbenefits.Similarly,temporaryincentiveshavebeenusedtotrytohelpindividualsdevelop

betterhealthhabits suchas exercise andquitting smoking.8Recently, temporary incentiveshave

4 SeeDasandHammer (2005);DasandGertler (2007);Das,HammerandLeonard (2008);Barberand

Gertler(2009);LeonardandMasatu(2010);GertlerandVermeersch(2012);andMonahan,M.etal.(2015).5FormoreevidenceoforganizationalinertiaservingasabarriertoCPGcomplianceseeGrol(1990);Hudak,

O’DonnellandMazyrka(1995);Main,CohenandDiClemente(1995);andPathmanetal.(1996).6Weuseadifferentdefinitionofhabitsthanthebehavioraleconomicsliteraturewherehabitsarebasedon

theaddictionofmodelsofBeckerandMurphy(1988).Instead,werelyonthenotionsoffastandslowthinkingdiscussedinKahneman(2012)wheretasksperformedbasedonfastthinkingbecomehabits.

7Payinganupfrontlumpsumamountisanotheroption.However,itmaybehardertoensureandverifytheactual change in practice patterns. By paying based on actual performance the incentives also include acommitmentdeviceforcompliance.

8SeeforexampleVolppetal.(2008);Volppetal.(2009);CharnessandGneezy(2009);Johnetal.(2011);Royeretal.(2012);CawleyandPrice(2013);andAclandandLevy(2015).

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beenusedtostimulatelong‐termsavingsintheformofinitiallyhighinterestratesandprice‐linked

savingsorlotteries(Gertleretal.2015,andSchaner2015).Toourknowledge,ourstudyisthefirst

to use a field experiment to examine the effects of temporary incentives on long‐run firm

performance.

Wetesttheeffectsoftemporaryincentivespaidtoclinicsforearlyinitiationofprenatalcare

usingafieldexperimentconductedwithPlanNacer,anArgentinegovernmentprogramthatprovides

health insurance tootherwiseuninsuredpregnantwomenandchildren.9Prenatal carebyskilled

healthprofessionalsbeginninginthefirsttrimesterofpregnancyisessentialforgoodmaternaland

newborn health outcomes, and is part of standardmedical training throughout theworld (WHO

2006).Throughearly initiationofcare,providersareable todetectandcorrect importanthealth

conditionssuchasinfectionsoranemiabeforetheyjeopardizematernalornewbornoutcomesas

wellasadvisemothersonproperprenatalnutritionandpreventionactivities(Schwarczetal.2001;

Carrolietal.2001aand2001b;CampbellandGraham2006).Despitetheserecommendationsand

the scientific evidence, take‐upof early initiationofprenatal care remains lowworldwide (WHO

2014).

Thefieldexperimentrandomizedtemporaryfinancialincentivestohealthcareclinicsinwhich

treatmentclinicswerepaida200%premiumforearlyinitiationofprenatalcare,i.e.beforeweek13.

Wefindthattherateofearlyinitiationofprenatalcarewas34%higherinthetreatmentgroupthan

in thecontrolgroup(0.42versus0.31)while the incentiveswerebeingpaid,andthat thehigher

levelsofearly initiationofprenatalcare inthetreatmentgrouppersistedat least15monthsand

likelymore than 24months after the incentives ended.We document that clinics changed their

routines by developing strategies to identify likely pregnant women and expanding the role of

communityhealthworkerstofindpregnantwomenandencouragethemtostartcareearly,andthat

thesechangesinroutinesalsopersistedatleast15monthsaftertheincentivesended.Despitethe

largeeffectof the incentivesonearly initiationof care,we findnoevidenceof aneffectonbirth

outcomes.

Ourresultsmayexplainthemechanismbehindrecentevidencethatpermanentperformance

incentives do indeed improve both quality and quantity of care.10 The standard neoclassical

9In2013,PlanNacerwasexpandedtootherpopulationsandrenamedProgramaSumar.10SeeforexampleBasingaetal.(2011);Floresetal.(2013);Bonfreretal.(2013);DeWalqueetal.(2015);

GertlerandVermeersch(2013);Gertleretal.(2014);andHuilleryandSeban(2014).MillerandBabiarz(2013)provideareview.

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explanationisthatprovidersarereallocatingtheireffortacrossservicesinresponsetotheincreased

profit opportunities.11 However, previous studies have been unable to distinguish between this

mechanismandorganizational inertia.Onewaytodistinguishbetweenthetwomechanismsis to

observewhathappenswhenincentivesareremoved.Whiletheincentivesareinplaybothmodels

predict a positive response.However, once the incentives are removed, practice patterns should

reverttopriorlevelsinthestandardmodelsbutcontinueatthehigherlevelsunderorganizational

inertia.

Understanding themechanism bywhich financial incentiveswork is not only scientifically

interesting,butalsopolicyrelevant.Iftemporaryfinancialincentivesareabletoinduceprovidersto

adoptpermanentchangestotheirclinicalpracticepatterns,thentemporaryincentivescanachieve

aboostinperformanceatasubstantiallycheapercostthanpermanentincentives.Ourresultssuggest

that the mechanism behind positive provider responses to price increases is more related to

adjustmentcoststhantorespondingtohigherprofitmargins. Inthiscase, long‐termincreases in

productivitycanbeachievedmorecheaplythanthroughapermanentincreaseinfees.

2 CONCEPTUALFRAMEWORK

Wedevelopastylizedmodelofclinicalpracticepatternswhereclinicsincurafixedcosttochange

clinicalpracticeroutines.Weassumethatpatientsareidentical,thatclinicsprovidethesameservices

toallpatients,andthatdemandisexogenouslydetermined.

ObjectiveFunction:Clinicshaveapay‐offfunction ∝ ,where isprofits,Hishealth

oftherepresentativepatient,N isthenumberofpatients,and∝∈ 0,1 istheprovider’s intrinsic

valueofaunitofpatienthealth.12As∝risesthecliniciswillingtosacrificemoreincomeforpatient

health.When∝takesonvalue0,theclinicispurelyextrinsicallymotivated,andwhen∝is1theclinic

ispurelyintrinsicallymotivated.Whileweallowforbothextrinsicandintrinsicmotivationinthe

model,alloftheresultsfollowevenwithpureextrinsicmotivation.Allowingforintrinsicmotivation

does not change the direction of the predictions just the magnitude. Moreover, pure intrinsic

11SeeBakeretal.(1988);HolmstromandMilgrom(1991);Gibbons(1997);andLazear(2000).12Thereisevidencetosupportintrinsicmotivationasatleastpartiallymotivatingmedicalcareproviders.

SeeforexampleLeonardandMasatu(2010);Kolstad(2013);andClemenesandGotlieb(2014).

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motivationby itselfdoesnotpredict that temporary incentiveswouldhave long termseffectson

productivity.13

HealthProductionFunction:Treatmenttechnology,asdefinedbyCPGs,involvestwoservices,

and where 1 if the clinic provides the service and 0 if not. If the clinic provides both

services,thenitisoperatingattheproductionpossibilitiesfrontier.Thehealthproductionfunction

fortherepresentativepatientis ,where isameanzerorandomshock.

ClinicalPracticeRoutine:Consideraclinicwhosecurrentclinicalpracticepatternroutineis

toprovide toallpatients.Inthiscase, istheclinic’sexistingclinicalpracticepatternroutine,and

isanadditionalservicethatthecliniccouldchoosetoaddtoitspracticeroutine.Iftheclinicwants

tointegratetheprovisionof intoitspracticepatternroutinethenitmustincuranupfrontfixed

costF.Thefixedcostincludesthecostofretoolingtobeabletoprovide ,thecostoflessreliable

serviceprovisionwhilethenewroutineisbeinglearned,andthecostofovercomingpsychological

resistancetochange.

Profits:Clinicsarepaid for andthemarginalcostofproviding toapatientis .Clinic

profitscanthenbeexpressedas:

∑ , (1)

where istheclinic’sdiscountrate.

Adoption:Theclinicadopts if

1 0 0 . (2)

Substitutionof(1)and(2) intothepay‐off functionandrearrangingtermsallowsustowritethe

conditionin(3)as:

∑ . (3)

13Withoutsomesortoffixedcostsofadjustment,bothintrinsicallyandextrinsicallymotivatedproviders

would still operate at the efficient frontier. Moreover, the intrinsic motivation literature suggests thatincentivescannegatively impactperformance.Thepsychology literature inparticularhas longargued thatperformance‐contingentincentivescanbedemotivatingforintrinsicallymotivatedworkers.ForexampleseeDeci(1971);PittmanandHeller(1987);Decietal.(1999);Deci(2001);EcclesandWigfiel(2002);DeciandRyan (2010). Benabou and Tirole (2003) embed these ideas in principle‐agent models that they use todemonstrate themechanisms throughwhich financial incentives can “crowd‐out” intrinsicmotivation andtherebynegativelyaffectperformance.Recentlaboratoryexperimentalevidenceonperformance‐contingentcontractsconfirmsthatincentivesinthepresenceofintrinsicmotivationcanresultinworseperformance.ForexampleseeFehrandFalk(1999);FehrandSchmidt(2000);GneezyandRuitichini(2000aand2000b);andArielyetal.(2009).

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Clinicsaremorelikelytoadopt iftheprofitmarginfrom ishigher,theyaremoreintrinsically

motivated,theeffectof onpatienthealthishigher,theyhavehigherpatientvolumes,andthey

havelowerdiscountrates.

Organizational inertia: Inertia is defined as when the present value of the fixed costs of

changing organizational routine prevents the clinic from adopting a valuable improvement to

production. The conditions are 0 and ∑ , i.e. is

valuablebutnotadoptedbecauseofthefixedcostofadjustingorganizationalroutinetobeableto

provide .Clinicswhoaremoreintrinsicallymotivated(i.e.higher )arelesslikelytobefrozenby

organizationalinertiaandmaybeevenwillingtolosemoneyinordertoadopt ,especiallyif is

veryproductive(i.e.higher ).

TemporaryIncentives:Organizationalinertiacanbeovercomewithatemporaryincreasein

,thepriceof .14Consideranincreasetothepricepaidinperiod1thatdisappearsinsubsequent

periods.Withoutlossofgeneralitywecansimplifythemodelto2periodswith asthediscountrate.

Inthiscase,theincreaseof in inperiod1necessarytoinducetheprovidertoadopt is:

≧ 1 . (4)

Thetemporaryincentive, ,atminimumcoverstheremainderofthefixedcostofadjustmentthatis

not paid for the discounted present value of the future stream of surplus generated from the

provisionof .Theincentivegoesdownwithscale ,theprofitmargin ,theextenttowhich

clinicsareextrinsicallymotivatedtimesthemarginalproductof inthehealthproductionfunction

,andthediscountrate.

Cross‐Price Effects:One concern voiced in the literature is that price increases for some

servicesmightleadtoareallocationofeffortfromotherservicesthatremainunchangedleadingto

negativecross‐priceeffects.Theimplicitunderlyingmodelinthesepapersisanindividualphysician

allocating time between activitieswith a time budget constraint. In ourmodel of amedical care

organization that can hire more staff, cross‐price effects are generated based on the nature of

economies of scope in either the health care production function or cost function. If both the

productionandcostfunctionsareadditivelyseparable,thentherearenocross‐priceeffects.Ifthe

14Thealternativeisalumpsumpaymentthatisvulnerabletothepossibilityofnoncomplianceandmaybe

difficulttoverify.However,atemporaryincreasein requirestheclinictochangeroutinesandactuallyadoptinordertogetpaid.Inthissensethetemporarypriceincreasealsoincludesacommitmentdeviceandhence

isexantepreferable.

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functionsarenotseparable,thenitispossibletohaveeithernegativeorpositivecross‐priceeffects

dependingthenatureofsubstitutabilityintheproductionandcostfunctions.

3 EXPERIMENTALDESIGN

ThefieldexperimentwasconductedbyPlanNacer,apublicinsuranceprogramthatbeganin2005

toimproveaccesstoqualityhealthcareforotherwiseuninsuredpregnantwomenandchildrenless

than6yearsold(Musgrove2010;Gertleretal.2014).LikeMedicaidintheU.S.andSeguroPopular

in Mexico, the national Plan Nacer program transfers funds to local governments, in this case

Provinces,whoarethenresponsibleforenrollingbeneficiaries,organizingtheprovisionofservices,

andpayingmedicalcareproviders.AninnovativefeatureoftheArgentineprogramisthatituses

financial incentives to ensure that beneficiaries receive high‐quality care. Financing from the

NationalleveltoProvincesisbasedfor60%onprogramenrollmentandfor40%onperformance.

Provincesthenusethosefundstopaypublichealthcarefacilitiesonafee‐for‐servicebasisforhealth

care provided to program beneficiaries. The national government determines the content of the

benefitspackage,whichisuniformacrossprovinces,whileprovincialgovernmentssetthepricethey

willpaytoprovidersforeachserviceinthatpackage.Healthfacilitiesarefreetochoosehowtouse

realizedrevenueswithinrelativelybroadguidelines.Some,thoughnotall,provincesallowhealth

facilitiestopaybonusestopersonnel.

PlanNacerscaledupbyfirstrecruitingandtrainingclinicsintheoperationsofitsprogram,

includingfeestructure,billing,andotherrules.Theprogramregularlyretrainstheclinicstokeep

themuptodateonanychangesandreinforceareasthatareperceivedtobeweak.Afterclinicsare

enrolled, clinic community outreach staff identify eligible women and children in the clinics’

catchmentareasinordertoenrollthemintotheprogram.Clinicoutreachstaffalsoregularlycontact

beneficiariestoencouragethemtotakeadvantageofprogrambenefits.

The field experiment was conducted with primary health care clinics in the Province of

Misiones,oneofthepoorestinthecountryandwithhighratesofmaternalandchildmortality.In

Misiones,theclinicisallowedtouseupto50%ofrevenuefromPlanNacerfeestopaybonusesto

facilitypersonnelatthediscretionofthefacilitydirector.TherolloutofPlanNacerinMisioneswas

completed in 2008 long before the pilot study. As such, both providers and beneficiaries were

knowledgeableoftheoperationofPlanNacerbeforetheexperimentbegan.

Theexperimentalinterventionwasdesignedtoencourageearlyinitiationofprenatalcarefor

PlanNacerbeneficiaries,therebyaligningtheincentivesinPlanNacerwithofficialArgentineclinical

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practice guidelines, medical school training, and international scientific evidence. Before the

experiment, only one‐third of Plan Nacer beneficiarieswere initiating care in the first trimester

(National Ministry of Health, 2009 and 2010). The experiment randomized temporary financial

incentivestoprimaryhealthcareclinicsinwhichtreatmentclinicswerepaida200%premiumfor

earlyinitiationofprenatalcare,i.e.beforeweek13.

Table 1 presents the payment schedule for the periods before, during and after the

intervention.Priortotheinterventionperiod,theprovincepaidfacilities$40ARSforeachprenatal

visitregardlessofwhenitoccurredorwhetheritwasthefirstorasubsequentvisit.15Duringthe

interventionperiodthefeewasincreasedto$120ARSfor1stvisitsthatoccurredbeforeweek13but

remainedat$40ARSforsubsequentvisits.Afterthat,theinterventionperiodfeesrevertedtothe

originalpaymentof$40ARSforallvisits.Themodificationamountedtoa3‐foldincreaseinthefee

for1stvisitsbeforeweek13.Themodifiedfeestructurewasimplementedfor8months‐fromMay

2010 toDecember2010. Facilities selected to receive themodified fee structurewere invited to

participateandnotifiedofthetime‐limitedimplementationonApril14,2010.Facilitydirectorswere

requiredtosignaformalmodificationoftheirexistingcontractwithPlanNacerinordertoreceive

themodifiedfeestructure.

The studydesign included37clinicsoutof262primarycare facilitiesof theprovince,of

which 18 were randomly assigned to the treatment group and were offered the modified fee

schedule.Theother19 formed thecontrolgroup.Table2shows that compliancewith treatment

assignmentwasnotperfect:outof18facilitiesassignedtothetreatmentgroup,14wereactually

treatedasthreerefusedtosigntheagreementandafourthclosedbeforetheinterventionstarted.In

addition, oneof the facilitiesoriginally assigned to the control groupwasmistakenlyoffered the

treatmentandagreedtothemodifiedfeestructure.Intheend,therewere36facilitiesinthestudy

excludingtheonethatclosed.

4 DATA

The Province of Misiones maintains a well‐developed and long‐established automated medical

recordinformationsystemmanagedbytheprovincialauthorities.Personnelatpublicprimaryhealth

clinics and hospitals digitize a record of each service provided to each patient. The data are of

unusually high quality in that key outcomes such as dates of visits, services delivered, andbirth

weightarerecordedatthetimeofcarebytheprovider;thereforewedonotneedtorelyonmaternal

15Theexchangeratefor$1ARSwasaround$0.25USDbetween2009through2011.

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recallofthesevariablescollectedinsurveyslongafterthevisit.Thedatausedintheanalysisare

extractedfromtheseclinicrecordsandcontaininformationontheuniverseofpatientsforthe36

clinicsinthestudy.Therecordsalsoincludetheindividual’snationalidentitynumber,whichisused

tolinktheindividualclinicmedicalrecordsfromprimaryhealthfacilitieswiththeregistryofhealth

insurancecoverage,theregistryofPlanNacerbeneficiaries,andhospitalmedicalrecords.Inall,97%

oftheprimaryclinicmedicalrecordsweremergedwiththedataoninsurancestatusandprogram

beneficiarystatus. Inaddition,75%of theseweresuccessfullymergedwithmedicalrecordsdata

fromhospitals.Thereforeouranalysis isabletoevaluatethe impactof the interventionforthose

womenwhoinitiatedtheirprenatalcareinoneoftheprimarycareclinicsofthesample.

4.1 ANALYSISSAMPLE

Figure2depictsthetimelineofthestudyandtheavailabilityofdatadividedinto4different

sub‐periods: (i) a16‐monthspre‐interventionperiod from January2009 toApril2010, (ii) an8‐

monthinterventionperiodfromMay2010toDecember2010,(iii)a15‐month“post‐intervention

periodI”fromJanuary2011toMarch2012and(iv)a9‐month“post‐interventionperiodII”from

April2012toDecember2012.

Prenatal care data was consistently collected for the first 3 periods from January 2009

throughMarch2012.StartinginApril2012,however,Misionesadoptedanewinformationsystem

andasaresultdata frompost‐interventionperiodIIcannoteasilybecomparedtodata fromthe

earlierperiods.Inparticular,thenewsystemchangedthecodesusedtoclassifythereasonforvisits

inordertofacilitatebilling.If inthefirstvisittheattendingphysicianrequestedanultrasoundto

confirmapregnancy,thisfirstvisitwaslabeledasa“carevisit”whilethesubsequent(second)visit,

waslabeledasthefirstprenatalvisit,ifindeedtheultrasoundconfirmedthepregnancy.Onaverage,

thiswouldledtoareductionintheshareofwomenwhohadavisitlabeledas“firstprenatalvisit”

beforeweek13andan increase intheweekspregnantat thetimeof thisvisit. If thenewcoding

system affected the treatment and control groups in the sameway, the differences between the

treatmentandcontrolgroupswouldstillcapturetheimpactoftheincentives,albeitpossiblywith

some measurement error. Therefore, we analyze the data from post‐intervention period II

separately,andinterprettheresultswithcaution.

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TheanalysissampleincludespregnantwomenwhowerebeneficiariesofPlanNaceratthe

timeoftheirfirstprenatalvisit.16Whileinformationonprenatalcareutilizationisavailableforthe

fullsampleperiod,informationrelatedtobirthoutcomesisonlyavailableforwomenwhogavebirth

inapublichospitalthrough2011,i.e.womenwhobecamepregnantbeforeMay2011.

4.2 MEASUREMENTOFWEEKSPREGNANTAT1STPRENATALVISIT

Weconstructthenumberofweeksofpregnancyatthetimeofthefirstprenatalvisitasthe

differencebetweenthedateofthefirstvisitandthelastmenstrualdate(LMD).TheLMDisroutinely

collected at the time of the visit to calculate the estimated date of delivery (EDD) and both are

routinelyrecordedinthepatient’smedicalrecordattheclinic.17

Onepotentialproblemisthatmedicalpersonnelintreatmentfacilitiesmightmisreportthe

dateoflatefirstvisitasoccurringbeforeweek13sothattheycouldbilltotheprogram.Wethink

thisisunlikelyforthefollowingreasons.First,theweekofvisitisconstructedfromthedateofthe

firstprenatalvisitandtheLMD,bothofwhichalongwiththeEDDarerecordedinrealtimeinthe

medicalrecord.Inordertofalselyreportthatafirstvisitoccurredinthefirst12weeks,theprovider

wouldhavetoalterthedateofthefirstvisitrelativetoeithertheLMDortheEDDinthemedical

record.Thiswouldrequiresomeeffortifdoneinrealtimeandwouldbenoticeablebyauditorsif

alteredexpost.Second,PlanNacerusesexternalauditorstoverifytheaccuracyofclinicbilling.The

auditorscomparethedetailedclinicalrecordstothebillingrequeststofindinconsistenciesandthe

lattercanleadtosubstantialfinancialpenaltiesfortheprovinces.Finally,clinicalrecordsarelegal

documentsinArgentinaandpractitionerscouldlosetheirmedicallicenseifcaughtsystematically

misreportingforfinancialgain.

Tocorroborateourbeliefthatfalsereportingintheclinicrecordsisunlikely,weempirically

testwhetherthereisanyevidenceofsystematicmisreportingusingdatafromanalternativesource.

Specifically,weusegestationalageatbirthmeasuredbyphysicalexaminationobtainedfromhospital

recordstoconstructasecondestimateoftheLMDandweekspregnantatthetimeofthefirstprenatal

visit.Thehospitalpersonnelthatattendthebirthdonothaveanyincentivetomisreporthospital

records.Wethencomparetheestimatedweekoffirstvisitbasedongestationalageatbirthtothe

16Weexcludednon‐beneficiariesbecausemostofthemhaveprivatehealthinsuranceandassucharelikely

toreceivesomeofcareanddeliveratprivatefacilities.Sincewedonothavedatafromprivatefacilities,theoutcomesofmostoftheseobservationsarecensored.

17For10%ofthesampleLDMwasnotrecorded.Forthosecases,weusetheEDDtorecovertheLMD.

11

weekoffirstvisitreportedbythehealthfacilities.Theresultsdonotshowanyevidenceofsystematic

misreportingduetoincentives.AppendixAprovidesadetaileddiscussionoftheanalysisandresults.

4.3 DESCRIPTIVESTATISTICSANDBASELINEBALANCE

Table3reportsthedescriptivestatisticsforthekeyoutcomesofinterestanddemographic

characteristics at baseline, i.e. in the 16‐month pre‐intervention period (Jan 2009 –April 2010).

Outcomes are balanced at baseline in that there are no statistically significant differences in the

meansofvariablesbetween the treatmentandcontrolgroups.Onaveragewomenhad their first

prenatalvisitabout17.5weeksintotheirpregnancywithaboutone‐thirdofwomenhavingthatvisit

beforeweek13.Womencompletedabout4.7prenatalvisitsoverthecourseoftheirpregnancyand

morethan80%ofthemreceivedatetanusvaccine.Newbornsweighedapproximately3,300grams

onaverage,whileabout6%ofthemwerebornwithlowbirthweight(i.e.lessthan2,500grams),and

slightlymorethan9%ofbirthswerebornprematurely.

5 IDENTIFICATIONANDESTIMATION

We estimate both the intent‐to‐treat (ITT) and local average treatment (LATE) effects of the

incentives on outcomes. The ITT is the effect of assigning a clinic to treatment on outcomes,

regardlessofcompliance.Itcomparesthemeanoutcomeofthegroupassignedtotreatmenttothe

meanoutcomeofthegroupassignedtocontrolandisestimatedbyregressingtheoutcomeagainst

anindicatorofwhethertheclinicwasassignedtotreatment.TheLATEistheeffectofaclinicactually

receiving the incentives and is estimated regressing the outcome againstwhether the clinicwas

actually treated, using the clinic’s randomized assignment status as an instrumental variable for

actualtreatment(ImbensandAngrist1994).Inbothcases,thetreatmenteffectisidentifiedoffthe

variation induced by the randomized assignment status. In the discussion of results in the next

section,wereporttheLATEestimates.18

Oursampleisclusteredwithin36healthclinicssincetherandomassignmentoftreatment

occurredatthecliniclevel.Assuch,theremaybeintra‐clustercorrelationthatmustbeconsidered

forstatisticalinference.Standardmethodsofcorrectingstandarderrorsrelyonlargesampletheory

bothinthenumberofobservationsandinthenumberofclusters.Giventhesmallnumberofclusters

inoursample,weinsteadusestatisticalinferencemethodsthatarerobusttorandomizedassignment

oftreatmentamongasmallnumberofclusters.Specifically,weusetheWildbootstrapmethodto

18TheITTresultsarealmostidenticaltotheLATEestimates,whichisexpectedgiventherelativelyhigh

complianceratestotheoriginalassignment.TheITTresultsarepresentedinAppendixC.

12

generatep‐values for hypothesis testing in ITTmodels (Cameron et al. 2008) and an analogous

method for hypothesis testing in the LATE models (Gelbach et al. 2009). Our Wild bootstrap

procedureassignssymmetricweightsandequalprobabilityafterre‐samplingresiduals,anduses

999replications(DavidsonandFlachaire2008).

6 TIMINGOFFIRSTPRENATALVISIT

In thissectionwereport theresultsofanalysesof theeffectsof the temporary incentiveson the

timingofthefirstprenatalvisitandmechanismsbywhichclinicsachievedthoseresults.

6.1 DENSITIES

Figure3comparesthedensitiesofweekspregnantatthetimeofthefirstprenatalvisitsfor

theclinicsassignedtothetreatmentandcontrolgroups.PanelAshowsthatthereisnodifference

betweenthedensitiesofthetreatmentandcontrolgroupsinthepre‐interventionperiod.PanelB

shows that the treatment group density is to the left of the control group density during the

interventionperiod.Finally,PanelCandDshowthatthetreatmentgroupdensityisplacedtotheleft

ofthecontrolgroupdensityduringpost‐interventionperiodsIandII.Kolmogorov‐Smirnovtestsfor

equalityofthedistributionscannotberejectedforthepre‐interventionanalysis,butarerejectedfor

the intervention and both post‐intervention periods with p‐values of 0.031, 0.004, and 0.009

respectively.Theseresultsimplythatthetemporaryincentivesledtoearlierinitiationofcareinthe

treatmentgroupcompared to the control group in the interventionperiodand that thesehigher

levelsofcarepersistedforatleast15monthsandlikelyfor24monthsandmoreafterthehigherfees

wereremoved.

6.2 SHORT‐RUNEFFECTS

Table4reportstheestimatesoftheeffectsofthetemporaryfeesontheearlyinitiationof

care.PanelAreportstheresultsforweekspregnantatthetimeofthefirstprenatalvisitandPanelB

reportstheresultsforwhetherthefirstvisitoccurredbeforeweek13.Thefirstcolumnreportsthe

resultsfortheinterventionperiodandthesecondandthirdcolumnsreporttheresultsforthepost‐

interventionperiods.Duringtheinterventionperiod,onaveragewomeninthetreatmentgrouphad

their1stvisitabout1.5weeksearlierintheirpregnancythanwomeninthecontrolgroup.Theshare

ofwomeninthetreatmentgroupwhohadtheir1stvisitbeforeweek13 is11percentagepoints

higherthanthecontrolgroup;approximately35%higherthanthecontrolgroup.Bothestimatesare

significantlydifferentfromzeroatconventionalp‐values.

13

6.3 LONG‐RUNEFFECTS

Ourmodel of behavioral inertiaprovided clearpredictions aboutproviderbehavior once

temporary incentives disappear: i.e. if the fee increase is enough to overcome the fixed costs of

adaptinganewpractice,clinicsshouldmaintainhigherlevelsofprenatalcareafterincentivesare

removed. Column 2 of Table 4 reports estimated impact of the temporary fee increase on early

initiationofcareinthe15‐monthperiodafterthefeeswereremoved. Onaverage,womeninthe

treatmentgroupstartedtheircare1.6weeksearlierthanthoseinthecontrolgroup.Thedifference

betweenthetreatmentandcontrolgroupsintheshareofwomenwhohadtheir1stvisitbeforeweek

13was8percentagepoints.Bothestimatesarestatisticallydifferentfromzeroatconventionallevels.

Further,wecannotrejectthenullhypothesisthattheimpactisdifferentintheinterventionandpost‐

interventionperiods.Theseresultsareconsistentwiththehypothesisthattemporaryincentiveshelp

overcomebehavioralinertiaandmotivatelong‐runchangesinperformance.

Whilethereisnosignificantdifferentbetweentheeffectduringtheinterventionandthepost‐

interventionperiods,oneconcernmaybethattheeffectoftreatmentslowlytrendedtowardszero

aftertheincentivesended.Totestthishypothesis,weplotthemeannumberofweekspregnantat

the time of first prenatal visit for treatment and control groups, before, during and after the

intervention(Figure4).19Wesplitthepre‐interventionperiodintotwosub‐periodsof6‐monthseach

andthepost‐interventionperiodinto3sub‐periods:thefirsttwoare6monthsandthethirdis3

months.Thetreatmenteffectisthedifferencebetweenthetwolines.Whilethetreatmentandcontrol

groupshavesimilartrendsbeforetheintervention,thetreatmentgroupappearstoreceiveearlier

careduringtheintervention,andthechangepersistsaftertheendoftheintervention.Noticethat

thereis little ifanyfalloffoverthepost‐interventionperiod.Ratherthetreatmenteffectsremain

fairlyconstantoverthe15‐monthpost‐interventionperiodI.Figure5depictsthesamerelationship

fortheshareofwomenwhoreceivecarebeforeweek13ofpregnancy.20Again,theeffectsofthe

interventionappeartocontinueatasteadyrateafteritisdiscontinued.

6.4 LONGER‐RUNEFFECTS

TheperiodofanalysisinourmainresultsisrestrictedtoJanuary2009toMarch2012.Recall

thatstarting inApril2012, thevisitcodingsystemchanged.Hencestarting inApril2012what is

reportedasfirstvisitsinthedataisactuallyamixoffirstandsecondvisits.Asaresulttheaverageof

weekspregnantatfirstvisitincreasesandtheshareofpregnantwomenwhosefirstvisitwasbefore

19 As discussed above, the information from post‐intervention period II (April‐December 2012) uses a

differentmetricandisthereforenotincludedinthisfigure.20Ibidem.

14

week13fallsrelativetopreviousperiods.Column3inTable4showstheresultsforthislastperiod.

Themeanaverageofweekspregnantatthetimeofthefirstvisitforthecontrolgroupissubstantially

higherforthisperiodthanforpreviousperiodsandthemeansharethathadtheirfirstvisitbefore

week13issubstantiallylower,suggestingthatthereismeasurementerrorinourmainoutcomein

thisperiod.However,thisdifferenceincodingshouldhaveasimilareffectintreatmentandcontrol

clinics given the randomized assignment of the treatment. Therefore the difference between

treatmentandcontrolclinicsshouldcanceloutthemeasurementerrorandprovideuswithunbiased

estimatesoftheimpact.

The results in Table 4 show a statistically significant reduction in the number of weeks

pregnantatthetimeofthefirstvisitandastatisticallysignificantincreaseintheshareofpregnant

womenwhohadtheirfirstvisitbeforeweek13.Theseresultssuggestthatimprovedproductivity

fromthetemporaryfeeincreasepersistedatleast24monthsafterthefeeswereremoved.

6.5 ROBUSTNESS

Weimplementthreerobustnesschecks.First,themainsamplemayincludepregnanciesthat

startinoneperiodandendinanother,whichcouldcloudtheeffectoftheincentivesontimingofthe

firstvisit.Forexample,awomanwhois6monthspregnantandhasnothadaprenatalvisitwhenthe

intervention starts and subsequently receivesher firstprenatal checkupduring the intervention,

wouldbe counted as a third trimester first visit during the interventionperiod, even though the

intervention cannot affect whether she receives prenatal care before week 13. Hence, in this

robustnesstestwere‐estimatethemodelsonarestrictedsamplewherewomenarenomorethan

onemonthpregnantinthefirstmonthoftheperiodandnolessthan3‐monthspregnantinthelast

monthoftheperiod.Theresults,reportedinPanelsBofAppendixTablesB1andB2,areveryclose

inmagnitudeandstatisticalsignificancetothemainresultsinTable4.

Second,eventhoughtherewerenostatisticaldifferencesinbaselinemeans,itispossiblethat

randomizationwas not able to fully balance the treatment and control groups on unobservable

characteristicsgiventhesmallnumberofclinics.Inordertotestforthispossibility,weestimatethe

modelsusingdifference‐in‐differenceswithclinicandmonthfixedeffects.Theresults,reportedin

PanelsCofAppendixTableB1andB2,areverycloseinmagnitudeandstatisticalsignificancetothe

mainresultsinTable4.

Finally,instudiesinvolvingasmallsampleofclustersthereisaconcernthatafewoutliers

maydrivetheaverageeffectfoundintheprevioussections.Weexplorethispossibilitybyestimating

clinic‐specifictreatmenteffectswherebywecompareeachtreatedclinicindividuallytothecontrol

15

clinicsasagroup.AppendixFiguresB1andB2plottheseindividualclinictreatmenteffectsforthe

outcomesofweekspregnantatthetimeofthefirstprenatalvisit(B1)andfortheprobabilityofthat

thefirstvisitoccurredbeforeweek13(B2),respectively.Theresultsaresortedalongthex‐axisfrom

the lowest to thehighest estimated effect,while thedashedblue line is the intent‐to‐treat effect

calculatedbypoolingtheinterventionandthefirstpost interventionperiod. Thesolidblackline

representsazerotreatmenteffect.Theverticallinesare95%confidenceintervalsconstructedusing

standarderrorsobtainedfromtheWildbootstrapprocedure.Thefiguresshowthatthehypothesis

ofnotreatmenteffectisrejectedfor11outof17clinicsinFigureB1and12outof17clinicsinFigure

B2.Inaddition,thetreatmenteffectshavetheexpectedsignin15out17clinicsinFigureB1and14

outofclinicsinFigureB2.Thisprovidesevidencethatourresultsarenotdrivenbyafewlarge‐effect

clinics.

6.6 MECHANISMS

Inordertobetterunderstandhowclinicswereabletoachievesuchlargeincreasesinthe

share ofwomenwho initiated prenatal care beforeweek 13,we conducted a series of in‐depth

interviewswithprofessionalsinasub‐sampleof5treatmentclinicsand3comparisonclinics.21We

findthattreatmentclinicsadoptednewpracticesandchangedroutinesinordertoincreaseearly

initiationof prenatal care.After the initial invitation toparticipate in the pilot, all 5 interviewed

treatmentclinicsorganizedateammeetingwiththestaffinordertodiscussstrategiestorespondto

thenew incentive scheme.Various treatment clinics adopteddifferent strategies, but all of them

involvedexpandingthescopeofworkofcommunityhealthworkerstoidentifyandencouragenewly

pregnantPlanNacertoinitiatetheirprenatalcareearly.Insomeclinics,thedirectorsupportedthe

change in strategiesby changing theway the financial incentivesweredistributedbetween staff

members.22Inparticular,someofthemstartedallocatingtheincentivesconditionalonthenumber

21The clinics interviewedare located inPosadas, the capital ofMisionesProvince.Each interview took

approximately45minutes.TheinterviewswerecarriedoutinMay2015.22Upto2013,anyhealthfacilityparticipatinginPlanNacerinMisioneswasabletouseupto10%oftheir

PlanNacerfundstopayincentivestopersonnel.Ifthefacilityachievedasetofhealthtargetsmeasuringusingperformance indicators (tracers) set by the province, that facilitywas able to use up to 50%of funds formonetaryincentivestohealthprofessionals.Thebonusescouldbeassignedtoanypersonworkingatthehealthfacility, includingthehealthworkers,administrativepersonnel,volunteers,andeventopersonnelaffiliatedwithotherprogramsaslongastheywerenotabsentformorethan10workingdaysinamonth,theydidnotparticipate in a strike organized by the union, and they were not subjected to a disciplinary sanction(suspensionwithoutpayordismissal). Inallcases, the finaldecisionregardingassignmentof incentivestopersonnelwastheprerogativeoftheclinicdirector.

16

ofpregnantwomenthateachteammemberbroughttotheclinicinamonth.Thisallocationfurther

incentivizedhealthworkerstotestnewpractices.

The in‐depth interviews uncovered several innovative strategies that treatment clinics

developedtoidentifypregnanciesearly.Forinstance,healthworkersstartedtofollowupwomen

who used birth control pills.23 Specifically community health workers prioritized home visits to

womenwhohadnotpickeduptheirpills.Second,healthworkersstartedtargetingwomenathigh

risk of not coming in for an early checkup. According to the interviewed doctors, mothers who

already have children are less likely to initiate their prenatal visits early in a new pregnancy.

However,manyof thesewomenarealsoeligible forweekly freemilkdistribution for theirolder

children.Healthworkersmetthesemothersatthetimeofthemilkdistribution,enquiredabouttheir

last menstruation date, and offered an instant‐read pregnancy test to those women whose

menstruationwasoverdue.Third,healthworkersidentifieddifficultiesinprovidingearlyprenatal

care toadolescents,as theymightbeunwilling torevealapregnancy,especially to theirparents.

Communityhealthworkersthereforedecidedtochangethetimingofhomevisits,soastoincrease

thechanceoffindingadolescentsbythemselves.Inoneoftheinterviewedclinics,theworkflowwas

modifiedsoastoensurepredictableavailabilityofagynecologistoncertaindaysoftheweek.This

inturnprovidedaneasywayforcommunityhealthworkersandadministrativestaff toschedule

patientappointments.Otherclinicsintroducednewwaysofkeepingtrackof“atrisk”patients,such

asanotebookthatkepttrackofanyvisitstothehomesofwomenthatwereatrisk,oramapthat

identified catchment areas of community health workers with corresponding (potential)

pregnancies.

We are able to substantiate the claims of increased outreach using clinic administrative

records on the number of community outreach activities that resulted in actual maternal‐child

serviceattheclinic.24Figure6displaystheaverageandmediannumberofoutreachactivitiesthat

resulted in actual maternal‐child services for the pre‐intervention, intervention, and post‐

interventionIperiods.25Theresultsshowthatthereislittledifferenceinoutreachactivitiesbetween

treatmentandcontrolclinicsinthepre‐interventionperiod.Intheinterventionperiodthetreatment

23Birthcontrolpillsaredispensedfreeofchargebyeachhealthfacility’spharmacyunit,thoughwomen

cannotcollectmorethanamonthlysupplyatanyonetime.Thepharmacyunitkeepsrecordsofallbirthcontrolpillcollections.

24 Plan Nacer finances clinic outreach activities on a fee‐for‐service basis and employs an externalindependentauditortoauditclinicactivityreports.Treatmentandcomparisonclinicswerepaidthesamefeefortheseactivitiesbefore,duringandaftertheexperiment.

25Themediansarebettermeasuresofcentraltendencyasthedensitiesofbothactivitiesareasymmetricheavilyskewedtotheright.

17

groupevidencedsubstantiallymoreactivitiesthanthecontrolgroup,andthisdifferenceissustained

throughthepost‐interventionperiod.

Weusethedatatoestimatethedifferencesinlognumberofactivitiesbetweenthetreatment

andcontrolgroups.Theresultsshownodifferencesinactivitiesinthepre‐interventionperiodand

positive and statistically significant higher levels of activities in the treatment clinics in the

interventionandpost‐interventionIperiods(Table5).Again,wecannotrejectthatthehypothesis

that the effects are different in the intervention and post‐intervention periods implying that the

increaseinsuccessfuloutreachactivitiespersistedafterthetemporaryincentiveswereremoved.

6.7 PSYCHOLOGICALBARRIERS

In theprevious subsectionwedocumented tangible costsof adjustment to increase early

initiationof prenatal care.An additionalpotential costof adjustment is psychologicalbarriers to

change.Onewaytoovercomepsychologicalresistanceistomaketheguidelineortaskmoresalient

inthemindsoftheclinicstaff.26Theissueisnotoneoflackofknowledgeorinformationasinitiating

care in the first trimesterhasbeen inCPGssince the1970sandhasbeena long‐standingpartof

standardmedicaleducation. Rathertheissueistheimportanceorprioritythatstaffplaceonthe

task.

Thetemporaryincentivesmighthaveincreasedtheimportanceofearlyinitiationofcarein

thestaff’sminds,therebymakingitahigherpriorityforaction.Thehigherthepriorityofatask,the

lesslikelypsychologicalbarrierswouldstandinthewayofadoption.Kahneman(2012,pp8)states

that“…frequentlymentionedtopicspopulatethemind…”morethanothersand“…peopletendto

assesstherelativeimportanceofissuesbytheeasewithwhichtheyareretrievedfrommemory”.As

such,salience“…isenhancedbymerementionofanevent”(Kahneman2012,pp331).Ifincomplete

ornon‐adoptionofataskisamatterofsaliencethentheobservedtreatmenteffectsmaybeexplained

bythefactthattemporaryincentiveshelptoovercomethistypeofpsychologicalbarriertochange.

Whilewedonothaveinformationonthesalienceofearlyinitiationofcareduringorshortly

aftertheexperiment,weexplorewhetherthetemporaryfeeincreasemadeearlyinitiationofcare

moreimportantinthemindsoftheclinicstaffaftertheendoftheexperiment,usinganonlinesurvey

administeredtothechiefmedicalofficerofeachclinicabouttheabsoluteandrelativeimportanceof

26 Taylor and Thompson (1982) define salience as, “…the phenomenon that when one's attention is

differentiallydirectedtooneportionoftheenvironmentratherthantoothers,theinformationcontainedinthatportionwillreceivedisproportionateweightinginsubsequentjudgments”.SeeBordaloetal.(2012,2013)foramorerecentdiscussionofsalienceandchoicetheory.SeeDeMeletal.(2013),andKarlanetal.(2015)forempiricalanalysisofsalienceeffectsthroughinformationalreminders.

18

seven different prenatal care procedures including initiating prenatal care prior to week 13 of

pregnancy(seeAppendixD).

Figures8and9comparetheabsolutescoreandrelativerankingoftheproceduresinterms

of importanceforprenatalcare.Theabsolutescoresranges from0to5,with5beingthehighest

whiletherelativerankingsortsthesevenpracticesfrom1to7,with1beingthehighestranking.Our

outcomes of interest are the absolute score and relative ranking assigned to early initiation of

prenatalcare.Figure8showsthattheabsolutescoreassignedtoearlyprenatalcareisonaverage

4.8inthetreatmentgroupand4.7inthecontrolgroup.Figure9showsthatonaveragetherelative

rankingforthispracticeisalsosimilarbetweenthetwogroups,2.0forthetreatmentgroupand1.9

for the control group.Moreover, thesedifferences arenot statistically significant at conventional

levels(seeAppendixD).Theseresultssuggestthattheearlyinitiationofprenatalcareisofsimilar

highabsoluteandrelativeimportanceandthattemporaryfeesdidnothavealastingeffectoneither

theabsolutenorrelativeimportance.

6.8 ALTERNATIVEEXPLANATIONS

One alternative explanation for the short‐term treatment effects is that the incentives are

causingtreatmentclinicstotrytoattractpregnantwomenwhootherwisewouldhaveusedother

clinics.Thisisunlikelytobetrueasbeneficiarywomenareassignedtospecificclinicswhenenrolled

inPlanNacer.Moreover,thenumberofpatientspermonthandthesharethatinitiatecarebefore

week13arethesameinthepre‐andpost‐interventionperiodsforcontrolclinics,andtheaverage

monthly number of patients is also the same in the pre‐ and post‐intervention periods for the

treatmentclinics.

Analternativeexplanationforlong‐runresultsisthatafterthetemporaryincentivesended,

womenwhowerepregnantduringtheinterventionperiodspassedthemessageoftheimportance

of early initiation of care onto other beneficiarywomenwho became pregnant during the post‐

interventionperiod.Hence,thepersistenceoftheeffectoftheincentivesaftertheincentivesmight

becausedbyan informationalspillover.However, thehigheramountof thecommunityoutreach

activities in treatment clinics, the mechanism used to generate higher early initiation of care,

continuedintothepost‐experimentalperiodatthesamelevelasintheinterventionperiod.Hence,if

therewere information spillovers in the post‐intervention period, then onewould expect to see

highertreatmenteffectsinthepost‐interventionperiodthanintheinterventionperiod.

Finally,onemightarguethattheclinicscontinuedthenewroutinesafterthetemporaryfees

wereeliminatedbecausetheyfacedalargefixedcostofrevertingtotheoldroutinesandnotbecause

19

thenewroutinesaddednetvalue.However,inthiscase,wethinkthatthefixedcostsofreversingthe

routinesweresmall,becausethecommunityhealthworkerscouldsimplyhavereturnedtotheirold

patternsofactivities.

7 CROSS‐PRICEEFFECTS(SPILLOVER)

Whilethemodifiedfeeschedulewasdesignedtoaffectthetimingofthefirstprenatalvisit,

wemightexpectproviderstoreduceeffortsuppliedtootherservices,resultinginalowerprovision

of such services to patients. We test for this by estimating the effect of the incentives on the

probabilityofpregnantwomenhavingavalidtetanusvaccine,andthenumberofprenatalvisits.The

resultspresentedinTable6reportnoevidenceofcross‐priceeffects,positiveornegative,ineither

theinterventionperiodorinpost‐interventionperiodI.Infact,thelevelsoftheseservicesappearto

beconstantovertime.Whiletheconcernaboutcrowding‐outistypicallyforacontextofindividual

providersfacingtimeandeffortconstraints,ourresultsareconsistentwithafirmsettingwherethere

arenooveralleffortortimeconstraints.

8 BIRTHOUTCOMES

Nextwe address thequestionofwhether the effect of the incentives for early initiationof

prenatal care translated into improved birth outcomes as measured by birth weight, low birth

weight,andprematurebirth.AsshowninFigure7andreportedinTable7wefindnoeffectofthe

incentivesonbirthoutcomesineithertheinterventionperiodorinthepost‐interventionperiod.

Thereareanumberofpossiblereasonsforthis.First,thesamplecouldbetoosmalltobeable

todetectastatisticallysignificanteffectonoutcomes.However,thepointestimatesareverysmall,

halfofthemarenegativeandtheyareofsimilarmagnitudetodifferencesbetweentreatmentand

controlgroupsinthepre‐interventionperiod.Second,giventhattheresultsonbirthoutcomesare

obtainedfromananalysisofasubsampleofbeneficiariesforwhomwewereabletomergeprenatal

carerecordswithhospitalmedicalrecords,itispossiblethattheresultsinTable4donotholdfor

thissubsample.Wethereforereplicatetheprenatalcareanalysisusingonlythesubsampleofwomen

forwhomhospitalmedicalrecordsareavailable.Overall,weobtainsimilarresultstothoseobtained

withthefullsample.27Third,despitethemedicalliteratureandCPGrecommendation,itispossible

that early initiation of carematters only a small amount for the general population of pregnant

27Resultsofthisanalysisareavailableuponrequest.

20

women,evenifearlyinitiationofcaremattersagreatdealforhigh‐riskpatients.Highriskpatients

include, among others, smokers, substance abusers, those with poor medical and pregnancy

histories,andthosewhostartprenatalcareverylateintheirthirdtrimesteroronlywhenaproblem

occurs.Itmaybethattheincreaseinearlyinitiationofcarecomesfromprimarilylow‐riskmothers

whoarelesslikelytobenefitfromearlyinitiationofcare.Onewouldthinkthatitwouldbeeasierto

persuade low‐riskmothers to come a littler earlier than to convince high‐riskmotherswho are

reluctanttocomeforanycareatall.

Infact,thisisconsistentwiththesmallreductionintheaverageweekspregnantatthetime

ofthefirstprenatalvisit.Onaverage,womeninthetreatmentgroupinitiatedprenatalcareabout

1.5weeks earlier thanwomen in the control group. Prenatal caremay affect birth outcomes by

diagnosingandtreating illnesssuchashypertensionandgestationaldiabetesaswellas trying to

changematernalbehaviorthroughpromotingactivitiessuchasgoodnutrition,notsmokingandnot

consumingalcohol.Iftheinterventionhadinducedhigh‐riskwomenwhootherwisewouldhavehad

1stvisitmuchlaterinthepregnancy,thentheincentivesmayhavehadameasurableimpactonbirth

outcomes.Hence,whiletheincentiveswereeffectiveinincreasingearlyinitiationofcare,theydid

notmanagetosufficientlyaffectthegroupmostlikelytobenefit.Thesolutionmightbetocondition

incentivesonattendinghigh‐riskwomen,butriskisdifficultandexpensivetoidentifyandverifyand

thereforemaynotbecontractible.

9 DISCUSSION

Weexaminetheeffectsoftemporaryfinancialincentivesformedicalcareproviderstoincreaseearly

initiationofprenatalcareforpregnantwomenusingarandomizedcontrolledtrialinArgentina.The

interventionrandomlyallocatesathree‐foldincreaseinthefeepaidtohealthfacilitiesforeachinitial

prenatalvisitthatoccursbeforeweek13ofpregnancy.Thispremiumwasimplementedforaperiod

of8monthsandthenended.Usingdataonhealthservicesandbirthoutcomesfrommedicalrecords,

weinvestigateboththeshort‐termeffectsoftheincentiveandwhethertheeffectspersistoncethe

directmonetarycompensationdisappears.

Our results suggest that the temporary incentives motivated long‐run changes in

performance.Wefindthattheincentivesledtopregnantwomenbeing35%morelikelytoinitiate

prenatalcarebeforeweek13andthatthehigherlevelsofearlyinitiationofcarepersistedforatleast

15monthsandlikelymorethan24monthsaftertheincentivesended.Theseresultsareconsistent

with a model of providers who face a fixed cost to changing their clinical practice routines, i.e.

21

organizational inertia.Temporary incentives inducedproviders to adopt changes to their clinical

practicepatternsbyhelpingthemtoovercomeinertia.Oncetheyadoptchangestopracticepatterns

thattheybelievearebeneficialtopatients,thechangespersistevenafterthemonetaryincentives

disappear.Theseresultsareconsistentwiththefindingsfromin‐depthinterviewsthatevidenced

thattreatmentclinicsadoptedinnovativepracticesandchangedroutinesinordertoincreaseearly

initiationofprenatalcare.

Ourstudyaddstothegrowingbodyofevidencethatincentivesareeffectiveinimproving

providerperformance.Ourresultsalsohaveanumberofimportantpolicyimplications.First,our

results suggest that temporary incentives may be effective in motivating long‐term provider

performanceat a substantially lower cost thanpermanent incentives. Second,whilewe find that

incentivesareabletomotivatechangesinclinicalpracticepatterns,wedidnotfindimprovements

inhealthoutcomes.Themonetaryincentivesthatwereimplementedwerenotabletosufficiently

reachthosewomenforwhomearlyinitiationofprenatalcarewouldhavethelargesthealthimpact.

Therefore,incentivesmaybemademoreeffectivebydefiningex‐antethepopulationmostlikelyto

benefit,andtailoringincentivestowardsthispopulation.However,tailoringincentivestohighrisk

populations or those most likely to benefit from the services may not be contractible as these

characteristics are typically not observable. This is maybe a major limitation of using incentive

contractstoimprovehealthoutcomes.

22

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27

FIGURESANDTABLES

Figure1:ProviderCompliancewithClinicalPracticeGuidelines

Source:Authors’elaborationbasedon(‐)Schusteretal.(1998);(+)Grol(2001);(++)Campbelletal.(2007);(*)DasandGertler(2007);and(#)GertlerandVermeersch(2012).

28

Figure2:TimelineandDataAvailability

29

Figure3:DensitiesofWeeksPregnantat1stPrenatalVisit

Notes:Densities estimatedusinganEpanechnikovkernelwithoptimalbandwidth.P‐valesofKolmogorov‐Smirnovtestsofequalityofdistributionsbetweengroupsreportedbelowfigure.Thetwoverticallinesindicateweeks13and20ofpregnancy.Source:Authors’ownelaborationbasedondatafromtheprovincialmedicalrecordinformationsystem.

30

Figure4:MeanNumberofWeeksPregnantat1stPrenatalVisit

Notes:Thefirsttwopoints(circles)aremeansfor6‐monthperiodspriortotheinterventionperiod.Thethirdpoint(Diamond)correspondstotheinterventionperiod.Thefourthandfifthpoints(triangles)correspondto6‐monthsperiodsaftertheinterventionperiod,whilethelastpoint(triangle)isfora3‐monthperiod.

31

Figure5:ProportionofMotherswith1stPrenatalVisitbeforeWeek13ofPregnancy

Notes:Thefirsttwopoints(circles)aremeansfor6‐monthperiodspriortotheinterventionperiod.Thethirdpoint(Diamond)correspondstotheinterventionperiod.Thefourthandfifthpoints(triangles)correspondto6‐monthsperiodsaftertheinterventionperiod,whilethelastpoint(triangle)isfora3‐monthperiod.

32

Figure6:NumberofClinicOutreachActivities

Notes:Theheightofthebarsreportthemeanandmediannumberofoutreachactivitiesthatresultedinactualmaternal‐childserviceattheclinic,pertrimesterforthepre‐interventionperiod(January2009‐April2010),theinterventionperiod(May‐December2010),andpost‐interventionperiodI(January2011‐March2012)

33

Figure7:BirthWeightDensities

Notes:Densities estimatedusinganEpanechnikovkernelwithoptimalbandwidth.P‐valesofKolmogorov‐Smirnov tests of equality of distributions between groups reported below figure. Source: Authors’ ownelaborationbasedonmedicalrecordinformationsystem.

34

Figure8:AbsoluteScoreofImportanceofPrenatalCareServices

Notes:Thisgraphreportstheaverageoftheabsolutescorethatmeasurestheimportancegivenbyclinicstosevendifferentprenatalcareproceduresincludinginitiatingprenatalcarepriortoweek13ofpregnancy.Thedatawerecollectedusingashortonlinesurveyconductedintheclinicsthatparticipatedintheexperiment.(seeAppendixD)Theabsolutescoresrangefrom1to5,with5beingthehighestscoreintermsofimportance.Therespondwascodedzeroiftherespondentreportedthatthisprocedureisinappropriateforapregnantwoman.

35

Figure9:RelativeRankingofImportanceofPrenatalCareServices

Notes:Thisgraphreportstheaverageof therelativerankingthatmeasuresthedegreeofprioritygivenbyclinics to seven different prenatal care procedures including initiating prenatal care prior to week 13 ofpregnancy.Thedatawerecollectedusingashortonlinesurveyconductedintheclinicsthatparticipatedintheexperiment.(seeAppendixD)Therelativescoresaimedtorankthesevenpracticesfrom1to7,with1beingthehighestranking.Inpracticehowever,thesurveyinstrumentallowedtherespondenttorepeatnumbers.

36

Table1:Paymentsfor1stPrenatalVisit

TimePeriod Dates Paymentfor1stPrenatalVisit

Begin End BeforeWeek

13ofpregnancy

Atweek13ofpregnancyor

after

Pre‐Intervention January2009 April2010 $40ARS $40ARS

Intervention May2010 December2010 $120ARS $40ARS

PostIntervention January2011 December2012 $40ARS $40ARS

Source:NationalMinistryofHealth,Argentina(2010b)

Table2:ClinicAssignmentandComplianceStatus

AssignedtoTreatment

ActuallyTreated

Total Yes No

Yes 14 4 18

No 1 18 19

Total 15 22 37

Source:Authors’elaboration.

37

Table3:BaselineDescriptiveStatistics

AssignedTreatmentGroup

AssignedControlGroup

p‐Valuefortestofequalityofmeans

Mean(s.d.) N

Mean(s.d.) N

Largesample

WildBoot‐

Strapped

WeeksPregnantat1stPrenatalVisit 17.5 743 17.6 497 0.89 0.84 (7.48) (7.74)

1stVisitbeforeWeek13ofPregnancy 0.35 743 0.33 497 0.57 0.56 (0.48) (0.47)

TetanusVaccineDuringPrenatalVisit 0.80 743 0.84 497 0.34 0.41 (0.40) (0.37)

NumberofPrenatalVisits 4.68 743 4.28 497 0.39 0.45 (2.94) (2.77)

BirthWeight(grams) 3,328 552 3,291 379 0.36 0.37 (519) (558)

LowBirthWeight(<2500grams) 0.06 552 0.06 379 0.96 0.98 (0.23) (0.23)

Premature(gestationalage<37weeks) 0.09 319 0.10 249 0.83 0.82 (0.29) 0.30

MaternalAge 25.36 354 25.75 270 0.47 0.48 (6.49) 6.10

NumberofPreviousPregnancies 2.31 354 2.10 273 0.29 0.32 (2.39) (2.10)

FirstPregnancy 0.25 354 0.26 273 0.70 0.77 (0.43) (0.44)

Notes:Thistablepresentsmeansandstandarddeviationsinparenthesesforthetreatmentandcontrolgroupsduringthe16‐monthpre‐interventionperiodfromJanuary2009throughApril2010.P‐valuesfortestsequalityof treatment and control groupsmeans are presented in the last 2 columns.Wepresent both thep‐valuecomputedforlargesamplesandaWildbootstrappedp‐valuethatisrobustinsampleswithsmallnumbersofclusters(Cameronetal.2008).OurWildbootstrapprocedureassignssymmetricweightsandequalprobabilityafterre‐samplingresiduals(DavidsonandFlachaire2008)anduses999replications.

38

Table4:EffectsonTemporaryIncentivesonTimingof1stPrenatalVisit

(1) (2) (3)

InterventionPeriodPost‐Intervention

PeriodI(Jan2011–March2012)

Post‐InterventionPeriodII

(April–Dec2012)

A.WeeksPregnantat1stPrenatalVisit

Treatment ‐1.47** ‐1.63** ‐2.47**

(0.71) (0.75) (1.02)

LargeSamplep‐value 0.04 0.03 0.02

WildBootstrappedp‐value 0.08 0.03 0.03

ControlGroupMean 17.80 17.90 20.10

SampleSize 769 1,296 710

B.FirstPrenatalVisitBeforeWeek13ofPregnancy

Treatment 0.11** 0.08** 0.08**

(0.04) (0.04) (0.04)





Notes:ThistablereportsLATEestimatesofthetreatmenteffectofthemodifiedfeescheduleonindicatorsofthe timing of the 1st prenatal visit. The differences are estimated from2SLS regressions of the dependentvariableonactualtreatmentstatusinstrumentedwithclinictreatmentassignmenttype.Thep‐valuesarefor2‐sidedhypothesistestsofthenullthatthedifferenceisequaltozero.Wepresentboththep‐valuecomputedforlargesamplesandaWildbootstrappedp‐valuethatisrobustinsampleswithsmallnumbersofclusters(Cameronetal.2008).OurWildbootstrapprocedureassignssymmetricweightsandequalprobabilityafterre‐samplingresiduals(DavidsonandFlachaire2008)anduses999replications.Column(1)reportstheresultsforthesampleobservedinan8‐monthinterventionperiod(May2010–December2010).Column(2)reportstheresultsforthesampleobservedinthe15‐monthperiodfollowingtheendoftheintervention(January2011–March2012).Column(3)reportstheresultsforthe9‐monthperiodafterthechangeinthecodingofthefirstprenatalvisit(April2012–December2012).Standarderrorsareinparentheses.*p<0.10,**p<0.05,***p<0.01.

39

Table5:ImpactonLogNumberofOutreachActivities

(1) (2)

InterventionPeriodPost‐InterventionPeriodI(Jan2011–March2012)

Treatment 0.47** 0.56** (0.23) (0.22)

LargeSamplep‐value 0.04 0.01

WildBootstrappedp‐value 0.04 0.02

Log(ControlGroupMean) 1.93 1.93

SampleSize 324 324

Notes:ThistablereportsLATEestimatesofthetreatmenteffectofthemodifiedfeeschedule.Thedependentvariableisthelogofthenumberofclinicoutreachactivitiesthatresultedinactualmaternal‐childserviceattheclinicpertrimester.Thep‐valuesarefor2‐sidedhypothesistestsofthenullthatthedifferenceisequaltozero.Wepresentboththep‐valuecomputedforlargesamplesandaWildbootstrappedp‐valuethatisrobustin samples with small numbers of clusters (Cameron et al. 2008). OurWild bootstrap assigns symmetricweights and equal probability after re‐sampling residuals (Davidson and Flachaire 2008) and uses 999replications.Theseareonlycomputedforthecoefficientsoftreatmentinteractedwitheachperiod.Standarderrorsareinparentheses.*p<0.10,**p<0.05,***p<0.01.

40

Table6:Cross‐PriceEffects(Spillover)

(1) (2)

InterventionPeriodPost‐InterventionPeriodI

(Jan–Dec2011)

A.TetanusVaccine

Treatment

0.02 ‐0.02 (0.08) (0.05)



ControlGroupMean 0.79 0.84

SampleSize 769 1,053

A.Numberofvisits

Treatment

0.39 0.51 (0.33) (0.58)





Notes:ThistablereportsLATEestimatesofthetreatmenteffectofthemodifiedfeescheduleonindicatorsofother services. The differences are estimated from 2SLS regressions of the dependent variable on actualtreatmentstatusinstrumentedwithclinictreatmentassignmenttype.Thep‐valuesarefor2‐sidedhypothesistestsofthenullthatthedifferenceisequaltozero.Wepresentboththep‐valuecomputedforlargesamplesandaWildbootstrappedp‐valuethatisrobustinsampleswithsmallnumbersofclusters(Cameronetal.2008).OurWildbootstrapprocedureassignssymmetricweightsandequalprobabilityafterre‐samplingresiduals(Davidson and Flachaire 2008) and uses 999 replications. Column (1) reports the results for the sampleobservedinan8‐monthinterventionperiod(May2010–December2010).Column(3)reportstheresultsforthesampleobservedinthe12‐monthperiodfollowingtheendoftheintervention(January2011–December2011).Standarderrorsareinparentheses.*p<0.10,**p<0.05,***p<0.01.

41

Table7:ImpactofIncentivesonBirthOutcomes

(1) (2)

InterventionPeriod Post‐InterventionPeriodI(Jan–Dec2011)

A.BirthWeight

Treatment

‐37.34 25.109 (48.61) (40.67)



ControlGroupMean 3,304 3,279

SampleSize 555 802

B.LowBirthWeight

Treatment

0.01 ‐0.01 (0.02) (0.02)




SampleSize 555 802

B.Premature

Treatment

0.03 ‐0.04 (0.03) (0.02)




SampleSize 414 708

Notes:ThistablereportsLATEestimatesofthetreatmenteffectofthemodifiedfeescheduleforonindicatorsof birthoutcomes. The observations includewoman forwhomweare able toobtain informationonbirthoutcomesprovidedinpublichospitalbirthrecords.Thedifferencesareestimatedfrom2SLSregressionsofthedependentvariableonactual treatment status instrumentedwithclinic treatmentassignment type.Thep‐valuesarefor2‐sidedhypothesistestsofthenullthatthedifferenceisequaltozero.Wepresentboththep‐value computed for large samples and a Wild bootstrapped p‐value that is robust in samples with smallnumbersofclusters(Cameronetal.2008).OurWildbootstrapprocedureassignssymmetricweightsandequalprobabilityafterre‐samplingresiduals(DavidsonandFlachaire2008)anduses999replications.Column(1)reportstheresultsforthesampleobservedinan8‐monthinterventionperiod(May2010–December2010).Column (2) reports the results for the sample observed in the 12‐month period following the end of theintervention(January2011–December2011).Standarderrorsareinparentheses.*p<0.10,**p<0.05,***p<0.01.

42

APPENDIXA:TESTOFMISREPORTINGWEEKSPREGNANTAT1STPRENATALVISIT

Oneconcernisthatthefinancialincentivesmaycauseclinicstomisreporttheweekofpregnancyat

thefirstvisit.Inthisappendixwereporttheresultsoftestforthisbehavior.Recallthatinourmain

analysisweconstructtheweekofpregnancyatthefirstvisitusingthedateofthefirstvisitandthe

last menstrual date (LMD) as reported by the women. If the latter is not available we use the

estimateddateofbirth(EDD)asrecordedbythephysicianinthefirstvisit.TheEDDiscalculatedoff

theLMDasreportedbythewomenduringherfirstvisit.Whileclinicmedicalrecordsshouldcontain

bothdates,about10%ofrecordsaremissingtheLMD.

OnepossiblewayofmisreportingtheweekofpregnancyatthefirstvisitistochangetheLMD

andtheEDDinthepatient’sclinicalmedicalrecord.Forinstance,ifawomanisinher21stweekof

pregnancyatthefirstvisit,thephysiciancouldadd7daystotheLMDandEDDsothatthevisitfalls

intothe20thweekofpregnancy.Bothwouldhavetobechangedinordertodeceivetheauditors.

To test for this possibility we use gestational age at birth (GAB) in weeks measured by

physicalexaminationatthetimeofbirth,registeredinthehospitalmedicalrecord.Wethencompare

theweekselapsedfromthefirstprenatalvisittothedeliverydatebasedonGABtoweekselapsed

fromfirstvisittothedeliverydatebasedonEDD.WhileEDDiscollectedbytheclinicwhohasan

incentive tomisreport, theGAB is collectedby thehospital at timeofdeliverywhere there isno

incentivetomisreport.

FigureA1plotsthenumberofweekstodeliveryfromthetimeofthe1stvisitbasedonGAB

(y‐axis)totheonebasedonEDD(x‐axis).Ifthereisnodifferencebetweenthetwomeasures,then

allofthedatesshouldfallonthe45‐degreeblueline.ThereshouldbesomedifferencesasEDDisan

estimatethatassumesnoprematurityatbirth,andtherecouldbedataentryinGABandEDDand

recallerrorsinEDD.FigureA1showsthatalmostallofthedataembracetheblue45‐degreelineand

mostoftheobservationsoffthelinearesituatedaboveit,consistentwithprematurityexplainingthe

differences.

IftheclinicchangestheEDDinordertocapturehigherpayments,wewouldexpectgreater

differences, for the treatment group, betweenGAB andEDDbelow the 12‐week thresholds than

aboveitduringtheinterventionperiodwhentheincentivesareinforce,butnodifferencesinthe

pre‐intervention period. In order to test this, we estimate the following difference in difference

regression:

13 13 (A1)

43

where isweeksofpregnantatthefirstvisitbasedonEDDforindividualigettingcareinclinic

j, isthenumberofweeksatthefirstvisitbasedonGABforindividualigettingcareinclinicj,

isaclinicfixedeffect, 13 isanindicatorofwhethertheclinicreportedthefirstvisitto

beinthefirst12weeksbasedonEDD, isanindicatorofwhethertheclinicwasactuallytreated,

and isanerrorterm.

Intheabsenceofmisreportingandnoprematuritythereshouldbenodifferencebetweenthe

twomeasuresand wouldhaveacoefficientof1.However,becauseprematurebirthsoccurbefore

EDD,weexpect tobeclosetobutlessthanone.Thenwecaninterprettheothercoefficientsasthe

effecton accountingforaverageweeksofprematurity.Sothedependentvariableis

theerrorinEDDinforecastingactualdeliverydate.Equation(A1)takesonadifferenceindifference

interpretationinthesensethewearedifferencingthechangeintheforecasterrorbetweenthepre‐

interventionandinterventionperiodsforthegroupofpregnantwomenforwhichaclinicreportsas

havingtheirfirstvisitbefore13weeksandthegroupofpregnantwomenforwhichaclinicreports

havingthefirstvisitinweek13orlater.Ifthereisnodifferenceintheerrorforthetreatmentgroup

inthepostperiodthen , theinteractionbetweentreatmentandreportedhavingthefirstperiod

beforeweek13,willbezero.Wefindnoevidenceofmisclassificationbytreatedclinics(SeeTable

A1).

44

FigureA1

ComparisonofWeeksPregnantat1stPrenatalVisitBasedonGestationalAgeatBirthandBasedonDateofLastMenstruation

Source:Authors’ownelaborationbasedondatafromtheprovincialmedicalrecordinformationsystem.

45

TableA1:TestforMisreportingWeeksPregnantat1stPrenatalVisit

DependentVariable:WeeksPregnantat1stPrenatalVisit,byGestationalAgeatBirth

WeeksPregnantbyEDD 0.90*** (0.02)

1(WeeksPregnantbyEDD<13) ‐0.13 (0.31)

1(WeeksPregnantbyEDD<13)x1(Treated=1) ‐0.03 (0.44)

Constant 1.33*** (0.39)

Observations 1730

AdjustedR2 0.82

Thedependentvariableisweekspregnantatthefirstprenatalvisitconstructedusinggestationalageatbirth.Theindependentvariableisweekspregnantatthefirstvisitconstructedbyusingthelastdayofmenstruationorestimateddeliverydate(EDD).Theinteractionterminteractsadichotomousindicatorforwhetherthevisitwasbeforeweek13andadichotomousindicatorforwhethertheclinicwasactuallytreated.Theregressioncontrolsforclinicfixedeffectsbyaddingabinaryindicatorforeachclinicinthesample.Standarderrorsareinparentheses.*p<0.10,**p<0.05,***p<0.01.

46

APPENDIXB:ROBUSTNESSTESTRESULTS

FigureB1:IndividualClinicTreatmentEffectsforWeeksPregnantat1stPrenatalVisit

Notes:Thisfigureplotsindividualclinictreatmenteffectsfortheoutcomeofweekspregnantatfirstprenatalvisit.WerunOLSregressionoftheoutcomecomparingeachclinicassignedtothetreatmentgrouptoallclinicsassignedtothecontrolgrouppoolingtheinterventionperiodandthepost‐interventionperiodI(henceMay2010‐March 2012). One treatment clinic is not included because of its insufficient sample size. This cliniccorrespondstooneofthetwothatdidnottakeuptreatment.Thetrianglesymbolreferstotheclinicthatwasassignedtotreatmentbutdidnottakeupthetreatment.Thex‐axisissortedfromthelowesttothehighestclinic‐specificimpact.Thedashedbluelineistheintent‐to‐treateffectcalculatedbypoolingtheinterventionand the first post intervention period. The vertical lines are 95% confidence intervals constructed usingstandarderrorsobtainedfromtheWildbootstrapprocedure.

47

FigureB2:IndividualClinicTreatmentEffectsfor1stPrenatalVisitbeforeWeek13ofPregnancy

Notes:Thisfigureplotsindividualclinictreatmenteffectsfortheoutcomeoffirstprenatalvisitbeforeweek13.WerunOLSregressionoftheoutcomecomparingeachclinicassignedtothetreatmentgrouptoallclinicsassignedtothecontrolgrouppoolingtheinterventionperiodandpostinterventionperiodI(henceMay2010‐March2012).Onetreatmentclinicisnotincludedbecauseofitsinsufficientsamplesize.Thiscliniccorrespondstooneofthetwothatdidnottakeuptreatment.Thetrianglesymbolreferstotheclinicthatwasassignedtotreatmentbutdidnottakeupthetreatment.Thex‐axisissortedfromthelowesttothehighestclinic‐specificimpact.Thedashedbluelineistheintent‐to‐treateffectcalculatedbypoolingtheinterventionandthefirstpost interventionperiod.Thevertical linesare95%confidenceintervalsconstructedusingstandarderrorsobtainedfromtheWildbootstrapprocedure.

48

TableB1:RobustnessTestsforWeeksPregnantat1stPrenatalVisit

(1) (2) (3)




(April–Dec2012)

A.ResultsfromTable4

Treatment ‐1.47** ‐1.63** ‐2.47**

(0.71) (0.75) (1.02)





B.EstimatesUsingRestrictedSample

Treatment ‐1.47* ‐2.01*** ‐2.01* (0.77) (0.70) (1.11)





C.Difference‐in‐DifferencesEstimates

Treatment ‐1.35** ‐1.74*** ‐2.35* (0.64) (0.63) (1.31)




SampleSize 4,015 4,015 4,015

Notes:ThistablereportsLATEestimatesofthetreatmenteffectofthemodifiedfeescheduleonweekspregnantat1stprenatalvisit.Thep‐valuesarefor2‐sidedhypothesistestsofthenullthatthedifferenceisequaltozero.Wepresentboththep‐valuecomputedfor largesamplesandaWildbootstrappedp‐valuethat isrobust insamples with small numbers of clusters (Cameron et al. 2008). Our Wild bootstrap procedure assignssymmetricweightsandequalprobabilityafterre‐samplingresiduals(DavidsonandFlachaire2008)anduses999replications.Column(1)reportstheresultsforthesampleobservedinan8‐monthinterventionperiod(May2010–December2010).Column(2)reportstheresultsforthesampleobservedinthe15‐monthperiodfollowingtheendoftheintervention(January2011–March2012).Column(3)reportstheresultsforthe9‐monthperiodafterthechangeinthecodingofthefirstprenatalvisit(April2012–December2012).Standarderrorsareinparentheses.*p<0.10,**p<0.05,***p<0.01.

49

TableB2:RobustnessTestsfor1stPrenatalVisitbeforeWeek13

(1) (2) (3)




(April–Dec2012)

A.ResultsfromTable4

Treatment 0.11** 0.08** 0.08**

(0.04) (0.04) (0.04)





B.EstimatesUsingRestrictedSample

Treatment 0.09** 0.10** 0.10* (0.04) (0.04) (0.06)





C.Difference‐in‐DifferencesEstimates

Treatment 0.09* 0.07 0.07 (0.05) (0.05) (0.06)




SampleSize 4,015 4,015 4,015

Notes:ThistablereportsLATEestimatesofthetreatmenteffectofthemodifiedfeescheduleanindicatorofwhetherthe1stprenatalvisitoccurredbeforeweek13ofpregnancy.Thep‐valuesarefor2‐sidedhypothesistestsofthenullthatthedifferenceisequaltozero.Wepresentboththep‐valuecomputedforlargesamplesandaWildbootstrappedp‐valuethatisrobustinsampleswithsmallnumbersofclusters(Cameronetal.2008).OurWildbootstrapprocedureassignssymmetricweightsandequalprobabilityafterre‐samplingresiduals(Davidson and Flachaire 2008) and uses 999 replications. Column (1) reports the results for the sampleobservedinan8‐monthinterventionperiod(May2010–December2010).Column(2)reportstheresultsforthe sampleobserved in the15‐monthperiod following theendof the intervention (January2011–March2012).Column(3)reportstheresultsforthe9‐monthperiodafterthechangeincodingofthefirstprenatalvisit(April2012–December2012).Standarderrorsinparentheses.*p<0.10,**p<0.05,***p<0.01.

50

APPENDIXC:ITTRESULTS

TableC1:ITTEstimatesoftheEffectofTemporaryIncentivesonTimingof1stPrenatalVisit

(1) (2) (3)

Intervention

Period

Post‐InterventionPeriodI

(Jan2011–March2012)


(April–Dec2012)

A.WeeksPregnantat1stPrenatalVisit

Treatment ‐1.39** ‐1.59** ‐2.47** (0.67) (0.73) (1.02)





B.FirstPrenatalVisitBeforeWeek13ofPregnancy

Treatment 0.10*** 0.08** 0.08** (0.04) (0.04) (0.04)





Notes:ThistablereportsITTestimatesofthetreatmenteffectofthemodifiedfeescheduleonindicatorsofthetimingofthe1stprenatalvisit.TheLATEestimatesarereportedinTable4.ThedifferencesareestimatedfromOLS regressionsof thedependentvariableonan indicator for clinic treatment randomassignment.Thep‐valuesarefor2‐sidedhypothesistestsofthenullthatthedifferenceisequaltozero.Wepresentboththep‐value computed for large samples and a Wild bootstrapped p‐value that is robust in samples with smallnumbersofclusters(Cameronetal.2008).OurWildbootstrapprocedureassignssymmetricweightsandequalprobabilityafterre‐samplingresiduals(DavidsonandFlachaire2008)anduses999replications.Column(1)reportstheresultsforthesampleobservedinan8‐monthinterventionperiod(May2010–December2010).Column (2) reports the results for the sample observed in the 15‐month period following the end of theintervention(January2011–March2012).Column(3)reportstheresultsforthe9‐monthperiodafterthechange in the coding of the first prenatal visit (April 2012 – December 2012). Standard errors are inparentheses.*p<0.10,**p<0.05,***p<0.01.

51

TableC2:ITTofCross‐PriceEffects(Spillover)

(1) (2)

InterventionPeriodPost‐InterventionPeriod

(Jan–Dec2011)

A.TetanusVaccine

Treatment 0.02 ‐0.02 (0.07) (0.05)





A.Numberofvisits

Treatment 0.37 0.50 (0.32) (0.57)





Notes:ThistablereportsITTestimatesofthetreatmenteffectofthemodifiedfeescheduleonindicatorsofotherservices.TheLATEestimatesarereportedinTable5.ThedifferencesareestimatedfromOLSregressionsofthedependentvariableonanindicatorforclinictreatmentrandomassignment.Thep‐valuesarefor2‐sidedhypothesistestsofthenullthatthedifferenceisequaltozero.Wepresentboththep‐valuecomputedforlargesamplesandaWildbootstrappedp‐valuethatisrobustinsampleswithsmallnumbersofclusters(Cameronetal.2008).OurWildbootstrapprocedureassignssymmetricweightsandequalprobabilityafterre‐samplingresiduals (DavidsonandFlachaire2008) anduses999 replications. Column (1) reports the results for thesampleobserved inan8‐month interventionperiod(May2010–December2010).Column(3)reports theresultsforthesampleobservedinthe12‐monthperiodfollowingtheendoftheintervention(January2011–December2011).Standarderrorsareinparentheses.*p<0.10,**p<0.05,***p<0.01.

52

TableC3:ITTEffectsofIncentivesonBirthOutcomes

(1) (2)

InterventionPeriod Post‐InterventionPeriod(Jan–Dec2011)

A.BirthWeight

Treatment ‐34.88 24.48 (45.38) (39.63)




SampleSize 555 802

B.LowBirthWeight

Treatment 0.01 ‐0.01 (0.02) (0.01)




SampleSize 555 802

B.Premature

Treatment 0.03 ‐0.04* (0.03) (0.02)




SampleSize 414 708

Notes:ThistablereportsITTestimatesofthetreatmenteffectofthemodifiedfeescheduleforonindicatorsofbirthoutcomes.TheLATEestimatesarereportedinTable6.Theobservationsincludewomanforwhomweareabletoobtaininformationonbirthoutcomesprovidedinpublichospitalbirthrecords.Thedifferencesareestimated from OLS regressions of the dependent variable on an indicator for clinic treatment randomassignment.Thep‐valuesarefor2‐sidedhypothesistestsofthenullthatthedifferenceisequaltozero.Wepresentboththep‐valuecomputedforlargesamplesandaWildbootstrappedp‐valuethatisrobustinsampleswith small numbers of clusters (Cameron et al. 2008). Our Wild bootstrap procedure assigns symmetricweights and equal probability after re‐sampling residuals (Davidson and Flachaire 2008) and uses 999replications.Column(1)reportstheresultsforthesampleobservedinan8‐monthinterventionperiod(May2010 – December 2010). Column (2) reports the results for the sample observed in the 12‐month periodfollowingtheendoftheintervention(January2011–December2011).Standarderrorsareinparentheses.*p<0.10,**p<0.05,***p<0.01.

53

APPENDIXD:ONLINESURVEYOFCLINICS

IncollaborationwiththeProvincialManagementUnitoftheprogram(UGPS),inMay2015

weconductedashortonlinesurvey(usingSurveyMonkey®)inthoseclinicsthatparticipatedinthe

pilot.Thesurveyaimstomeasuretheabsoluteandrelativeimportanceofsevendifferentprenatal

careproceduresincludinginitiatingprenatalcarepriortoweek13ofpregnancy.Theabsolutescores

rangefrom1to5,with5beingthehighestscoreintermsofimportance,andanadditionaloptionof

zero indicating that theprocedure isnotappropriate forapregnantwoman.Hence, theabsolute

scorerangesfrom0to5points.Therelativerankingaimedtosortthesevenpracticesfrom1to7,

with1beingthehighestranking.Inpracticehowever,thesurveyinstrumentallowedtherespondent

torepeatnumbers.

Thesurveywassentouttobyemailtoclinicsdirectors(orthenextpersoninrank).Wewere

unable to obtain current email addresses for8 out of the 36 clinics.Another4 clinics confirmed

havingreceivedtheemailbutrefusedtoanswerit.Outofthe24clinicsthatdidrespondtothesurvey,

21 fully completed it while 3 only partially completed it. Out of the 21 clinics with complete

responses,13belongtothetreatmentgroupand8tothecontrolgroup.AppendixTableD1shows

thattherearenosignificantdifferencesinbaselinecharacteristicsbetweenclinicsthatrespondedto

thesurveyandclinicsthatdidnotrespond.Inaddition,weaccountforsurveynon‐responseusing

InverseProbabilityWeightingbasedon the logistic regressionreported inTableD2(Wooldridge

2007).WereportresultsforbothIPWandnon‐IPWregressions.

Figures8and9donotsuggestanydifferenceintheabsolutescoreandrelativerankingofthe

procedures between treatment and control clinics. To test for the significance of the differences

betweenthetwogroups,werunanOLSregressionoftheabsolutescoreandtherelativeranking

againstabinaryindicatorfortreatment.Toaccountforthesmallsamplesizewealsocomputethep‐

value for the differences in means permuting our data and using a random sample of 10,000

permutations.TheresultsareshowninTablesD3andD4.

54

OnlineSurveyQuestionnaire

Weaskforyourcollaborationincompletingabriefsurveyaboutprenatalcareservicesprovidedatyourhealthfacility.

Important:Whenansweringthesurvey,pleasethinkofahypotheticalcaseofawomanwiththefollowingcharacteristics:

25yearsold Livinginthesameneighborhoodwhereyourhealthfacilityislocated Withoutanyapparentsignofdisease 6weekspregnant Hadapreviouslow‐riskpregnancy

1. Pleaseassignascorebetween1to5toeachofthefollowingservicesthatcouldbe

deliveredtothepregnantwomanpresentedinthehypotheticalcase.

1correspondstoaservicetowhichyouassignthelowestimportance5correspondstoaservicetowhichyouassignthehighestimportance

1 2 3 4 5

Notappropriateforapregnantwoman

Prenatalultrasound

ThoraxX‐Ray

Firstprenatalvisitbeforeweek13ofpregnancy

Bio‐psycho‐socialpregnancycounselingvisit

CombinedDiphtheria/Tetanusvaccine

Bloodtestwithserology

Bloodtestwithoutserology

55

Pleaserankinorderofpriority(from1to7)thefollowing7healthservicesthatcouldbedeliveredtothepregnantwomanofthehypotheticalcase.

1correspondstotheserviceyouwouldprioritizethemost7correspondstotheserviceyouwouldprioritizetheleast

Prenatalultrasound

ThoraxX‐Ray

Firstprenatalvisitbeforeweek13ofpregnancy

Bio‐psycho‐socialpregnancycounselingvisit

CombinedDiphtheria/Tetanusvaccine

Bloodtestwithserology

Bloodtestwithoutserology

56

TableD1:BaselineCharacteristicsofClinics,byOnlineSurveyResponseStatus

Non‐

respondent Respondent P‐value Obs.

NumberofPregnantWomenAttendedperYear 48.60 64.90 0.33 36

WeeksPregnantat1stPrenatalVisit 17.44 16.77 0.15 36

1stVisitbeforeWeek13ofPregnancy 0.34 0.38 0.27 36

%ofPregnantWomenwhoarePlanNacerBeneficiaries 0.61 0.64 0.59 36

TetanusVaccineDuringPrenatalVisit 0.74 0.81 0.22 36

NumberofPrenatalVisits 4.26 4.42 0.72 36

BirthWeight(Grams) 3,283 3,320 0.33 36

GestationalAge(Weeks) 38.65 38.47 0.57 31

LowBirthWeight(<2500Grams) 0.06 0.07 0.73 31

Premature(GestationalAge<37Weeks) 0.10 0.13 0.60 31

Notes:This table reports themeansofbaselinecharacteristics for clinics that responded to theMay2015online survey and for clinics thatdidnot respond.The characteristics are taken from themedical recordsinformationsystem(2009).Thep‐valuesforthetestsofdifferencesinmeansarecomputedusingpermutationteststhatarerobustforsmallsamplesizes.

57

TableD2:ProbabilityofRespondingtotheOnlineSurvey,LogitCoefficientsandMarginalEffects

Coeff. Marg.Eff.

TreatmentGroup 1.498 0.274 (1.111) (0.180)

BirthWeight(grams) 0.100 0.018 (1.076) (0.196)

WeeksPregnantat1stPrenatalVisit ‐0.594 ‐0.109 (0.648) (0.121)

1stVisitbeforeWeek13ofPregnancy ‐3.590 ‐0.657 (9.026) (1.670)

%ofPregnantWomenwhoarePlanNacerBeneficiaries 1.620 0.296 (4.359) (0.774)

TetanusVaccineDuringPrenatalVisit 3.350 0.613 (3.817) (0.646)

NumberofPrenatalVisits ‐0.099 ‐0.018 (0.559) (0.101)

Constant 7.644 (18.248)

Observations 36 36

Notes: This table reports the coefficients and marginal effects from a logit regression that estimates theprobabilitythataclinicrespondedtotheMay2015onlinesurvey.

58

TableD3:DifferencesinAbsoluteScoreandRelativeRankingofEarlyPrenatalCare

AbsoluteScore RelativeRanking

(1)OLS

(2)OLS‐IPW

(3)OLS

(4)OLS‐IPW

Difference(Treatment–Control) 0.20 0.13 0.10 0.14 (0.22) (0.92) (0.21) (0.89)

LargeSamplep‐value 0.38 0.89 0.65 0.88

Permutationp‐value 0.35 1.00 0.46 0.99

Observations 20 20 20 20

Controlgroupmean 4.57 1.88 4.66 1.88

Notes:Column(1)showsthedifferencesbetweentreatmentandcontrolclinicsintheabsolutescoreassignedtothepracticeofearlyprenatalcarewithoutanyadjustmentofsampleloss.Column(2)adjustsforsamplelossbyInverseProbabilityWeighting.Column(3)showsthedifferencesbetweentreatmentandcontrolclinicsintherelativerankingassignedtoearlyprenatalcareamongsevendifferentpractices.Column(4)isthesameasColumn(3)butadjustsforsamplelossbyInverseProbabilityWeighting.(Wooldridge2007)ThecoefficientsareobtainedfromanOLSregressionofeachoutcomeagainstatreatmentbinaryindicator.ThethirdrowshowstheP‐valueobtainedfrompermutingthedatausingarandomsampleof10,000permutations.Standarderrorsareinparentheses.Weloseoneobservationineachcasebecauseofmissingdataineachspecificquestion.

long-run effects of temporary incentives on medical care … · 2016-07-08 · fernando bazán...

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