Multitasking and Heterogeneous Treatment Effects in Pay-for-Performance in Health Care: Evidence from Rwanda
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-randomized roll-out of Rwanda’s national pay-for-performance (P4P) program to
analyze impacts on utilization of healthcare 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.
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Manoj Mohanan
Associate Professor in the Sanford School of Public Policy
Manoj Mohanan is an applied microeconomist, focusing on health and development economics,
with a background in medicine and public health. His research focuses on topics related
to health and health care in developing countries including: performance-based contracts,
measurement of provider quality and performance, social franchising, and social accountability
/ monitoring. He also studies the role of subjective expectations and beliefs in
health care behavior.Several of his

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