Staff supervision and financial incentives improve in-hospital mortality in childhood malaria
published 08-11-2007
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Bottom line: In this government hospital in Guinea-Bissau, mortality from childhood was reduced by 50% in an intervention that monitored and supervised staff supervision to guidelines, and also provided extra $$ to the staff as an incentive.
This clever study studied the effect of close adherence to guidelines using structured supervision of nurses and doctors, combined with financial incentives, on survival in childhood malaria. Children were randomized to one of two wards, control or intervention. All the staff were retrained in caring for patients with malaria, and all the children received free drugs for treatment. See "read more" for more details and discussion, or read the full article free.
The intervention is described thus:
All staff working on the intervention ward rigorously followed the procedures recommended in the national standardised guidelines on the management of malaria and filled in the case record forms; the doctors evaluated the nurses' quality of work and the study supervisor systematically controlled the quality of implementation of the recommended procedures. Results of supervision were registered in the form. Nurses and doctors received a small amount of money ($50/month for nurses and $160 for doctors) for the additional forms they had to fill out. This is roughly what they would earn if they did extra part time work and is equivalent to monthly rent in Bissau for these categories of staff.
Children assigned to the intervention ward were re-evaluated by the study doctor on duty until 10 pm. The nurse on duty called one of the study doctors if a seriously sick child was recruited after 10 pm. The nurses on this ward could make management decisions themselves when the study doctor was not present.
The authors point out that one cannot distinguish the effects of the supervision, stringent guidelines, filling forms, and financial incentives, since all were used together in the intervention group. However, they point out (speculate?) that it is unlikely that the other interventions would have been successful without the added motivation of extra money. The incentives were not trivial: nurses received an additional US $50 (6100 naira equivalent) monthly, and the doctors an extra $80 (10,000) monthly.
Is this is a good news/bad news story? The good news is that the hospital mortality, and presumably overall standard of care, can be improved with methods and incentives. But I can see several immediate concerns (bad news):
In a hospital system, private or government, already struggling with a large payroll, how will the increased pay be achieved?
If the important factor is the incentive, the boost in salary for a period of time or for a special project, what happens when the "project" finishes? or
If the extra money is actually incorporated long term as increased salary, will it still have any effect as an incentive, or will the new, higher salaries simply be a new baseline from which additional "incentives" will need to be offered?
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