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Effects of team-based goals and non-monetary incentives on front-line health worker performance and maternal health behaviours: a cluster randomised controlled trial in Bihar, India
  1. Suzan L Carmichael1,
  2. Kala Mehta1,
  3. Hina Raheel1,
  4. Sridhar Srikantiah2,
  5. Indrajit Chaudhuri3,
  6. Shamik Trehan2,
  7. Sunil Mohanty2,
  8. Evan Borkum4,
  9. Tanmay Mahapatra2,
  10. Yingjie Weng5,
  11. Rajani Kaimal5,
  12. Anita Sivasankaran4,
  13. Swetha Sridharan4,
  14. Dana Rotz4,
  15. Usha Kiran Tarigopula6,
  16. Debarshi Bhattacharya6,
  17. Yamini Atmavilas6,
  18. Wolfgang Munar7,
  19. Anu Rangarajan4,
  20. Gary L Darmstadt1
  21. Ananya Study Group
    1. 1Department of Pediatrics and Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, USA
    2. 2CARE India, Patna, India
    3. 3Project Concern International, Delhi, India
    4. 4Mathematica Policy Research, Princeton, New Jersey, USA
    5. 5Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, California, USA
    6. 6The Bill and Melinda Gates Foundation, Delhi, India
    7. 7Department of Global Health at the George Washington University Milken Institute School of Public Health, Washington, DC, USA
    1. Correspondence to Dr Gary L Darmstadt; gdarmsta{at}


    Introduction We evaluated the impact of a ‘Team-Based Goals and Incentives’ (TBGI) intervention in Bihar, India, designed to improve front-line (community health) worker (FLW) performance and health-promoting behaviours related to reproductive, maternal, newborn and child health and nutrition.

    Methods This study used a cluster randomised controlled trial design and difference-in-difference analyses of improvements in maternal health-related behaviours related to the intervention’s team-based goals (primary), and interactions of FLWs with each other and with maternal beneficiaries (secondary). Evaluation participants included approximately 1300 FLWs and 3600 mothers at baseline (May to June 2012) and after 2.5 years of implementation (November to December 2014) who had delivered an infant in the previous year.

    Results The TBGI intervention resulted in significant increases in the frequency of antenatal home visits (15 absolute percentage points (PP), p=0.03) and receipt of iron-folic acid (IFA) tablets (7 PP, p=0.02), but non-significant changes in other health behaviours related to the trial’s goals. Improvements were seen in selected attitudes related to coordination and teamwork among FLWs, and in the provision of advice to beneficiaries (ranging from 8 to 14 PP) related to IFA, cord care, breast feeding, complementary feeding and family planning.

    Conclusion Results suggest that combining an integrated set of team-based coverage goals and targets, small non-cash incentives for teams who meet targets and team building to motivate FLWs resulted in improvements in FLW coordination and teamwork, and in the quality and quantity of FLW–beneficiary interactions. These improvements represent programmatically meaningful steps towards improving health behaviours and outcomes.

    Trial registration number NCT03406221

    • community health worker
    • teamwork
    • coordination
    • primary healthcare
    • performance-based incentives

    This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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    • Handling editor Valery Ridde

    • Collaborators Ananya Study Group: Y Atmavilas, D Bhattacharya, E Borkum, SL Carmichael, I Chaudhuri, A Creanga, GL Darmstadt, P Dutt, L Irani, R Kaimal, T Mahapatra, KM Mehta, R Mitra, W Munar, K Pepper, H Raheel, A Rangarajan, N Saggurti, P Sastry, J Schooley, H Shah, S Srikantiah, U Kiran Tarigopula, V Ward, Y Weng, S Wahid, J Wilhelm.

    • Contributors The study was conceived by IC, ST, SM, UKT, DB and YA, and designed by IC, ST and SM. EB, AS, SS, DR and AR designed the evaluation and participated in data acquisition and management. Data analysis was conducted by HR, KM, YW and RK, with oversight by SLC and GLD. HR, KM, YW, RK, SLC and GLD participated in interpretation of data. SLC and GLD wrote the first draft of the manuscript. All authors critically reviewed the paper, provided intellectual content and approved the final version of the paper for publication.

    • Funding This study was supported by a grant from the Bill and Melinda Gates Foundation.

    • Competing interests None declared.

    • Patient consent for publication Obtained.

    • Ethics approval Institutional Review Board of the Public Health Foundation of India, New Delhi.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available upon reasonable request.