Generosity Norms and Intrinsic Motivation in
Health Care Provision:
Evidence from the Laboratory and the Field
J. M. Brock1
1 European
K. L. Leonard3
Bank for Reconstruction and Development
London, UK
2 Department
3 Department
Brock, Lange, Leonard (UMD)
A. Lange2
of Economics University of Hamburg
of Agricultural and Resource Economics
University of Maryland
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Outline
1
Motivation is an important source of performance
2
Research Design
3
Results
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Motivation in Health Care
Health Care in Low Income Countries
caring for the welfare of patients is important and not fully
contractible
effort can be measured by researchers (with predictable
difficulties)
rational effort can be specified in protocol
effort is relatively low
effort, and therefore, outcomes can be improved without
significant investment in new resources
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Common views of Intrinsic Motivation in the Literature
A health worker is “intrinsically motivated"
I
I
I
I
discrete (yes/no) characteristic
If they are intrinsically motivated then they do not need outside
stimuli to serve the poor/sick/etc.
Increases in Extrinsic Motivation (wages/bonuses/etc) will increase
the effort of extrinsically motivated health workers, but maybe not
intrinsically motivated workers.
Extrinsic motivation may harm intrinsic motivation.
In the management literature:
I
I
caring for the welfare of patients is extrinsic motivation
only loving the job itself is intrinsic motivation
In the behaivoral economics literature:
I
I
People have pro-social motivation
This motivation is context dependent
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Is there such a thing as an Intrinsically Motivated
Health Worker?
We expand on hybrid view (essentially ignoring the management
literature):
The broad idea of Intrinsic motivation does matter in health care
I
I
I
Most health workers have Proscocial Preferences and will respond
to prosocial motivators
Extrinsic motivation means you work harder when the monetary
wage is increased
prosocial motivation means you work harder when the proscoial
wage is increased
Thus, intrinsic motivation is not a characteristic of the health
worker but a characteristic of his or her environment
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Outline
1
Motivation is an important source of performance
2
Research Design
3
Results
Brock, Lange, Leonard (UMD)
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Our Investigation
Goal
I
I
I
To measure something we can link to altruism (or generosity) as an
inate characteristic
To see how all clinicians respond to changes in prosocial incentives
To see if altruistic clinicians respond differently to prosocial
incentives
Measure the quality of care (protocol adherence as reported by
patients interviewed as they leave the facility) provided by 103
clinicians in their normal practices
I
I
I
Baseline
Subject to the scrutiny of a peer
After encouragement from a peer
63 of these clinicians took part in a laboratory experiment where
they played a dictator game and were given the opportunity to give
a part of their endowment to anonymous strangers drawn from the
local population (‘patients’)
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Field Interventions
Baseline
I
we interview patients after they have left the consultation and ask
them specific questions that we can use to measure protocol
adherence (avoiding the hawthorne effect)
Scrutiny (Direct Peer Observation)
I
I
I
I
We send a peer into the consultation room to observe
Can use this to validate the reports of patients
Causes a Hawthorne effect, often leading to an increase in quality
We also measure quality right after the peer leaves the room (post
scrutiny)
Encouragement (Peer visit and 2 research visits)
I
I
I
I
I
I
Visited by a peer, told their work is important, asked to work harder.
Five items are deliberately mentioned (tracked items)
They know they are part of a research study
They know we will return to measure the quality of care by
interviewing their patients
No direct extrinsic motivation.
Data analyzed is from 6 weeks after this intervention (with two
intervening visits to collect data)
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Outline
1
Motivation is an important source of performance
2
Research Design
3
Results
Brock, Lange, Leonard (UMD)
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The Dictator Game (a measure of ‘generosity’)
#
subj.
mean
tokens given
SD
Med.
Mode
63
35.03
19.77
50
40
x =0
% of subjects with
0 < x < 50 x = 50
x ≥ 50
3.17%
58.73%
7.94%
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30.16%
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Does generosity mean anything in the field?
Dependent Variable: Quality at the Baseline
whether a doctor provides
protocol
a particular item
adherence
(1)
(2)
(3)
(4)
generous
item effects
patient effects
N
0.092***
(0.010)
yes
G,A
7994
0.086***
(0.335)
yes
G, A
8002
0.082***
(0.020)
yes
G, A
8002
0.067***
(0.020)
none
G, A, MS
358
Marginal Effects reported. significant at 1% (***), 5% (**), and 10% (*)
(1): Logit regression with dummies for item effect, controlling for gender (G) and age
(A) of patient;
(2) logit regression with random effects at the unique patient level, with dummies for
item effect, controlling for gender (G) and age (A) of patient;
(3) linear regression with fixed effects for each unique item, controlling for gender (G)
and age (A) of patient, clustered at the unique patient level;
(4) linear regression of patient average, controlling for gender (G), age (A) and major
symptom (MS)
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Protocol Adherence and Field Interventions
peer scrutiny (Scr.)
post scrutiny
encouragement (Enc.)
Enc. tracked (Trk.)
clinician fixed effects
item effects
patient effects
patient order
N
Brock, Lange, Leonard (UMD)
(1)
(2)
(3)
(4)
0.031***
(0.005)
0.016**
(0.001)
0.059***
(0.005)
0.044***
(0.007)
yes
yes
G,A
-0.001
(0.001)
41007
0.027***
(0.010)
0.015
(0.011)
0.055***
(0.009)
0.041***
(0.006)
yes
yes
G, A
0.000
(0.001)
41007
0.035***
(0.013)
0.020
(0.014)
0.058***
(0.011)
0.073***
(0.010)
yes
yes
G, A
-0.001
(0.001)
41007
0.030**
(0.012)
0.022
(0.014)
0.080***
(0.010)
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yes
none
G, A, MS
0.000
(0.001)
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How should generous clinicians respond to field
interventions?
If they are altruistic or intrinsically motivated:
I
I
they may care that they are being watched, but they should not
increase their adherence to protocol
Altruistic doctors are already doing what they should be doing for
their patients
If they have prosocial preferences and respond to environmental
conditions that allow them to gain utility from giving to others (our
lab experiment)
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They may respond to incentives in the normal workplace and
provide higher effort
and they will additionally respond to incentives from changes in the
normal workplace the same way as health workers who did not
respond in the lab experiment.
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Generosity and the Response to Field Interventions
peer scrutiny (Scr.)
encouragement (Enc.)
Enc. tracked (Trk.)
generous, Scr.
generous, Enc.
generous Trk.
clinician effects
item effects
patient effects
N
Brock, Lange, Leonard (UMD)
(1)
(2)
(3)
(4)
0.033***
(0.006)
0.053***
(0.007)
0.047***
(0.008)
-0.006
(0.011)
0.012
(0.010)
-0.002
(0.014)
yes
yes
G,A
35296
0.026**
(0.012)
0.054***
(0.012)
0.042***
(0.007)
0.002
(0.021)
0.000
(0.019)
0.004
(0.012)
yes
yes
G, A
35296
0.038**
(0.017)
0.057***
(0.014)
0.073***
(0.013)
-0.005
(0.026)
0.000
(0.020)
0.008
(0.014)
yes
yes
G, A
35296
0.025*
(0.015)
0.08***
(0.012)
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0.011
(0.023)
-0.006
(0.020)
yes
none
G, A, MS
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Changes in Patient Satisfaction
satisfied
would return
overall rating
satisfaction factor
skill rating
manner
value
scrutiny
encouragement
-0.001
(0.008)
0.04
(0.041)
0.051
(0.067)
0.029
(0.032)
0.029
(0.031)
0.038
(0.037)
0.059
(0.037)
0.026**
(0.012)
0.041
(0.048)
0.135**
(0.058)
0.099**
(0.039)
0.052
(0.049)
0.078
(0.054)
0.056
(0.048)
N
2362
2418
2376
2349
2403
2119
2123
Including clinicians fixed effects and patient characteristics. Errors clustered at the
facility level
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Conclusions
The average health worker cares what other people think and
responds to the presence and encouragement of a peer
Even those health workers who are generous to help strangers
and who it appears are more likely to help their patients
This suggests multiple sources of motivation which are additive
(not substitutes)
Prosocial motivation in health care may be much stronger in
reaction to peers than it is to patients
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