Re-aligning Incentives to Address Informal Payments in Tanzania Public Health Facilities: A Discrete Choice Experiment.

BACKGROUND: Informal payments for healthcare are typically regressive and limit access to quality healthcare while increasing risk of catastrophic health expenditure, especially in developing countries. Different responses have been proposed, but little is known about how they influence the incentives driving this behaviour. We therefore identified providers' preferences for policy interventions to overcome informal payments in Tanzania. METHODS: We undertook a discrete choice experiment (DCE) to elicit preferences over various policy options with 432 health providers in 42 public health facilities in Pwani and Dar es Salaam region. DCE attributes were derived from a multi-stage process including a literature review, qualitative interviews with key informants, a workshop with health stakeholders, expert opinions, and a pilot test. Each respondent received 12 unlabelled choice sets describing two hypothetical job-settings that varied across 6-attributes: mode of payment, supervision at facility, opportunity for private practice, awareness and monitoring, measures against informal payments, and incentive payments to encourage noninfraction. Mixed multinomial logit (MMNL) models were used for estimation. RESULTS: All attributes, apart from supervision at facility, significantly influenced providers' choices (P<.001). Health providers strongly and significantly preferred incentive payments for non-infraction and opportunities for private practice, but significantly disliked disciplinary measures at district level. Preferences varied across the sample, although all groups significantly preferred the opportunity to practice privately and cashless payment. Disciplinary measures at district level were significantly disliked by unit in-charges, those who never engaged in informal payments, and who were not absent from work for official trip. 10% salary top-up were preferred incentive by all, except those who engaged in informal payments and absent from work for official trip. CONCLUSION: Better working conditions, with improved earnings and career paths, were strongly preferred by all, different respondents groups had distinct preferences according to their characteristics, suggesting the need for adoption of tailored packages of interventions.

How can we elicit health workers' preferences for measures to reduce informal payments? A mixed methods approach to developing a discrete choice experiment in Tanzania.

OBJECTIVE: While discrete choice experiments (DCEs) have been used in other fields as a means of eliciting respondent preferences, these remain relatively new in studying corrupt practices in the health sector. This study documents and discusses the process of developing a DCE to inform policy measures aimed at addressing informal payments for healthcare in Tanzania. DESIGN: A mixed methods design was used to systematically develop attributes for the DCE. It involved five stages: a scoping literature review, qualitative interviews, a workshop with health providers and managers, expert review and a pilot study. SETTING: Dar es Salaam and Pwani regions in Tanzania. PARTICIPANTS: Health workers and health managers. RESULTS: A large number of factors were identified as driving informal payments in Tanzania and thus represent potential areas for policy intervention. Through iterative process involving different methods (qualitative and quantitative) and seeking consensus views by diverse actors, we derived six attributes for a DCE: mode of payment, supervision at the facility level, opportunity for private practice, awareness and monitoring, disciplinary measures against informal payments and incentive payment for staff if a facility has less informal payments. 12 choice sets were generated and piloted with 15 health workers from 9 health facilities. The pilot study revealed that respondents could easily understand the attributes and levels, answered all the choice sets and appeared to be trading between the attributes. The results from the pilot study had expected signs for all attributes. CONCLUSIONS: We elicited attributes and levels for a DCE to identify the acceptability and preferences of potential policy interventions to address informal payments in Tanzania through a mixed-methods approach. We argue that more attention is needed to the process of defining attributes for the DCE, which needs to be rigorous and transparent in order to derive reliable and policy-relevant findings.

Supply-side factors influencing informal payment for healthcare services in Tanzania.

Informal payments for healthcare are widespread in sub-Saharan Africa. They are often regressive, potentially limiting access to quality healthcare, particularly for the most vulnerable, and can have catastrophic consequences for households. Yet there is little empirical research that uses theory-driven hypotheses to explore what influences informal payments and, especially, from health workers' perspectives. Consequently, we have explored the characteristics of health workers and facilities influencing informal payments in Tanzania, examining two hypotheses: health workers with power and position in the system are more likely to receive informal payments, and transparency and accountability measures can be bypassed by those who can game the system. We conducted a cross-sectional survey of 432 health workers from 42 public health facilities (hospitals and health centres) in 12 district councils from Pwani and Dar es Salam regions in Tanzania. Our dependent variable was whether the health worker has ever asked for or been given informal payments or bribes, while explanatory variables were measured at the individual and facility level. Given the hierarchical structure of the data, we used a multilevel mixed-effect logistic regression to explore the determinants. Twenty-seven percent of 432 health workers ever engaged in informal payment. This was more common amongst younger (<35 years) health workers and those higher in the hierarchy (specialists and heads of departments). Those receiving entitlements and benefits in a timely manner and who were subject to continued supervision were significantly less likely to receive informal payments. The likelihood of engaging in informal payments varied among health workers, consistent with our first hypothesis, but evidence on the second hypothesis remains mixed. Thus, policy responses should address both individual and system-level factors, including ensuring adequate and progressive health sector financing, better and timely remuneration of frontline public health providers, and enhanced governance and supervision.

Bringing Production Back into Development: An introduction.

Production was at the heart of economics from the days of Classical economics. However, with the rise of Neoclassical economics in the late 19th century, production has lost its status as the ultimate interest of economics. Several opportunities for fruitful integration of alternative streams of economics research-Evolutionary, Structuralist and Keynesian in particular-have been also missed. Even the humanist approaches to development, such as Sen's Human Capability Approach, paid little attention to the domain of production. In this article, we argue that the fragmentation of the production-centred paradigm has weakened both academic research and policy-making related to economic development. We introduce and discuss eight articles developed around the special issue theme of Bringing Production Back into Development. We argue that a renewed 'productionist' agenda is essential to address the structural challenges faced by developing countries, even more so after the revelation of structural weaknesses by the pandemic.

La production était au cœur de l'économie depuis l'époque de l'économie classique. Cependant, avec l'essor de l'économie néoclassique à la fin du XIXe siècle, la production a perdu son statut de centre d'intérêt ultime de l'économie. Ont également été manquées plusieurs opportunités d'intégration fructueuse avec des courants alternatifs de recherche en économie, en particulier l'évolutionnisme, le structuralisme et le keynésianisme. Même les approches humanistes du développement, telles que l'approche par les capacités humaines de Sen, n'accordaient que peu d'attention au domaine de la production. Dans cet article, nous soutenons que la fragmentation du paradigme centré sur la production a affaibli à la fois la recherche universitaire et l'élaboration des politiques liées au développement économique. Nous présentons et discutons de huit articles développés autour du thème de ce numéro spécial, « Le retour de la production au sein du développement ¼. Nous soutenons qu'un programme «productiviste¼ renouvelé est essentiel pour relever les défis structurels auxquels sont confrontés les pays en développement, et plus encore après la dynamique accélérée insufflée par la pandémie.