The World Health Organization recommends that community health workers (CHWs) receive a mix of financial and non-financial incentives, yet notes that there is limited evidence to support the use of one type of incentive (i.e. financial or non-financial) over another. In preparation for a larger scale trial, we investigated the acceptability and feasibility of two different forms of incentives for CHWs in Malang District, Indonesia. CHWs working on a cardiovascular disease (CVD) risk screening and management programme in two villages were assigned to receive either a financial or non-financial incentive for 6 months. In the financial incentives village, CHWs (n = 20) received 16,000 IDR (USD 1.1) per patient followed up or 500,000 IDR (USD 34.1) if they followed up 100% of their assigned high-risk CVD patients each month. In the non-financial incentive village, CHWs (n = 20) were eligible to receive a Quality Care Certificate for following up the highest number of high-risk CVD patients each month, awarded in a public ceremony. At the end of the 6-month intervention period, focus group discussions were conducted with CHWs and semi-structured interviews with programme administrators to investigate acceptability, facilitators and barriers to implementation and feasibility of the incentive models. Data on monthly CHW follow-up activity were analysed using descriptive statistics to assess the preliminary impact of each incentive on service delivery outcomes, and CHW motivation levels were assessed pre- and post-implementation. Factors beyond the control of the study significantly interrupted the implementation of the financial incentive, particularly the threat of violence towards CHWs due to village government elections. Despite CHWs reporting that both the financial and non-financial incentives were acceptable, programme administrators questioned the sustainability of the non-financial incentive and reported CHWs were ambivalent towards them. CHW service delivery outcomes increased 17% for CHWs eligible for the non-financial incentive and 21% for CHWs eligible for the financial incentive. There was a statistically significant increase (p < 0.0001) in motivation scores for the performance domain in both villages. It was feasible to deliver both a performance-based financial and non-financial incentive to CHWs in Malang District, Indonesia, and both incentive types were acceptable to CHWs and programme administrators. Evidence of preliminary effectiveness also suggests that both the financial and non-financial incentives were associated with improved motivation and service delivery outcomes. These findings will inform the next phase of incentive design, in which incentive feasibility and preliminary effectiveness will need to be considered alongside their longer-term sustainability within the health system.

中文翻译：

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评估针对印度尼西亚农村社区卫生工作者的基于财务与行为激励的干预措施的可行性和可接受性

世界卫生组织建议社区卫生工作者 (CHW) 接受财务和非财务激励措施的混合，但指出支持使用一种激励措施（即财务或非财务）优于另一种激励措施的证据有限。为了准备更大规模的试验，我们调查了印度尼西亚玛琅区两种不同形式的 CHW 激励措施的可接受性和可行性。在两个村庄从事心血管疾病 (CVD) 风险筛查和管理计划的 CHW 被分配接受为期 6 个月的经济或非经济奖励。在财政奖励村，如果 CHWs（n = 20）每个月对指定的高风险 CVD 患者进行 100% 的随访，则每位患者的随访可获得 16,000 IDR（1.1 美元）或 500,000 IDR（34.1 美元）。在非财政奖励村，CHW（n = 20）有资格获得质量护理证书，以跟踪每月最多数量的高风险 CVD 患者，该证书在公共仪式上颁发。在 6 个月的干预期结束时，与 CHW 进行了焦点小组讨论，并与项目管理人员进行了半结构化访谈，以调查激励模型的可接受性、促进因素和实施障碍以及可行性。使用描述性统计分析每月 CHW 后续活动的数据，以评估每个激励措施对服务交付结果的初步影响，并在实施前后评估 CHW 动机水平。研究无法控制的因素显着中断了财务激励的实施，特别是由于村政府选举而对 CHW 的暴力威胁。尽管 CHW 报告财务和非财务激励措施都可以接受，但项目管理人员质疑非财务激励措施的可持续性，并报告 CHW 对它们持矛盾态度。有资格获得非财务奖励的 CHW 的 CHW 服务交付结果增加了 17%，有资格获得财务奖励的 CHW 的服务交付结果增加了 21%。两个村庄的绩效领域的动机得分都有统计学显着增加（p < 0.0001）。向印度尼西亚玛琅地区的 CHW 提供基于绩效的财务和非财务激励是可行的，并且这两种激励类型都为 CHW 和项目管理者所接受。初步有效性的证据还表明，财务和非财务激励措施都与动机和服务交付结果的改善有关。这些发现将为激励设计的下一阶段提供信息，其中需要考虑激励的可行性和初步有效性以及它们在卫生系统内的长期可持续性。