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Multitasking and Heterogeneous Treatment Effects in Pay-for-Performance in Health Care: Evidence from Rwanda

Author

Listed:
  • Tisamarie B. Sherry

    (Brigham and Women's Hospital)

  • Sebastian Bauhoff

    (Center for Global Development)

  • Manoj Mohanan

    (Duke University)

Abstract

Performance-based contracting is particularly challenging in health care, where multiple agents, information asymmetries, and other market failures compound the critical contracting concern of multitasking. As performance-based contracting grows in developing countries, it is critical to better understand not only intended program impacts on rewarded outcomes, but also unintended program impacts such as multitasking and heterogeneous program effects in order to guide program design and scale-up. We use two waves of data from the Rwanda Demographic and Health Surveys collected before and after the quasi-experimental rollout of Rwanda's national pay-for-performance (P4P) program to analyze impacts on utilization of health-care services, health outcomes, and unintended consequences of P4P. We find that P4P improved some rewarded services, as well as some services that were not directly rewarded, but had no statistically significant impact on health outcomes. We do not find evidence that clearly suggests multitasking. We find that program effects vary by baseline levels of facility quality, with most improvements seen in the medium-quality tier.

Suggested Citation

  • Tisamarie B. Sherry & Sebastian Bauhoff & Manoj Mohanan, 2017. "Multitasking and Heterogeneous Treatment Effects in Pay-for-Performance in Health Care: Evidence from Rwanda," American Journal of Health Economics, University of Chicago Press, vol. 3(2), pages 192-226, Spring.
    • Handle: RePEc:ucp:amjhec:v:3:y:2017:i:2:p:192-226
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    Cited by:

    1. Ye, Xiaoyang & Zhai, Muxin & Feng, Li & Xie, A’na & Wang, Weimin & Wu, Hongbin, 2022. "Still want to be a doctor? Medical student dropout in the era of COVID-19," Journal of Economic Behavior & Organization, Elsevier, vol. 195(C), pages 122-139.
    2. Bauhoff,Sebastian Peter Alexander & Kandpal,Eeshani, 2021. "Information, Loss Framing, and Spillovers in Pay-for-Performance Contracts," Policy Research Working Paper Series 9687, The World Bank.
    3. Manoj Mohanan & Katherine Donato & Grant Miller & Yulya Truskinovsky & Marcos Vera-Hernández, 2021. "Different Strokes for Different Folks? Experimental Evidence on the Effectiveness of Input and Output Incentive Contracts for Health Care Providers with Varying Skills," American Economic Journal: Applied Economics, American Economic Association, vol. 13(4), pages 34-69, October.
    4. Ngo, Diana K.L. & Bauhoff, Sebastian, 2021. "The medium-run and scale-up effects of performance-based financing: An extension of Rwanda’s 2006 trial using secondary data," World Development, Elsevier, vol. 139(C).
    5. Jeannette Brosig-Koch & Mona Groß & Heike Hennig-Schmidt & Nadja Kairies-Schwarz & Daniel Wiesen, 2025. "Physicians’ incentives, patients’ characteristics, and quality of care: a systematic experimental comparison of performance-pay systems," International Journal of Health Economics and Management, Springer, vol. 25(2), pages 217-243, June.
    6. Groß, Mona & Hennig-Schmidt, Heike & Wiesen, Daniel, 2023. "Personality and physician performance pay: Evidence from a behavioral experiment in health," HERO Online Working Paper Series 2023:5, University of Oslo, Health Economics Research Programme.
    7. Ahmad Reshad Osmani, 2021. "Conditional Cash Incentive and Use of Health Care Services: New Evidence from a Household Experiment," Journal of Family and Economic Issues, Springer, vol. 42(3), pages 518-532, September.
    8. Laura Anselmi & Julius Ohrnberger & Eleonora Fichera & Pedroso Nhassengo & Quinhas F. Fernandes & Sergio Chicumbe, 2023. "The impact of performance‐based financing within local health systems: Evidence from Mozambique," Health Economics, John Wiley & Sons, Ltd., vol. 32(7), pages 1525-1549, July.
    9. Finn McGuire & Peter C. Smith & Nicholas Stacey & Ijeoma Edoka & Noemi Kreif, 2025. "Do health care quality improvement policies work for all? Distributional effects by baseline quality in South Africa," Health Economics, John Wiley & Sons, Ltd., vol. 34(1), pages 175-199, January.
    10. Singh, Neha S. & Kovacs, Roxanne J. & Cassidy, Rachel & Kristensen, Søren R. & Borghi, Josephine & Brown, Garrett W., 2021. "A realist review to assess for whom, under what conditions and how pay for performance programmes work in low- and middle-income countries," Social Science & Medicine, Elsevier, vol. 270(C).
    11. Hao Zhang & Eddy van Doorslaer & Ling Xu & Yaoguang Zhang & Joris van de Klundert, 2019. "Can a results‐based bottom‐up reform improve health system performance? Evidence from the rural health project in China," Health Economics, John Wiley & Sons, Ltd., vol. 28(10), pages 1204-1219, October.

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    Keywords

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    JEL classification:

    • I1 - Health, Education, and Welfare - - Health
    • I15 - Health, Education, and Welfare - - Health - - - Health and Economic Development
    • J13 - Labor and Demographic Economics - - Demographic Economics - - - Fertility; Family Planning; Child Care; Children; Youth
    • J33 - Labor and Demographic Economics - - Wages, Compensation, and Labor Costs - - - Compensation Packages; Payment Methods
    • M52 - Business Administration and Business Economics; Marketing; Accounting; Personnel Economics - - Personnel Economics - - - Compensation and Compensation Methods and Their Effects
    • O12 - Economic Development, Innovation, Technological Change, and Growth - - Economic Development - - - Microeconomic Analyses of Economic Development

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