Financially incentivized knowledge assessments to improve provider compliance with treatment guidelines: a cluster-randomized controlled trial

Background: Despite increasing access to health care, under-5 mortality remains high in many parts of Sub-Saharan Africa. Interventions to improve quality of care have mostly focused on additional training for medical staff, but generally shown little impact We will assess the impact of financially incentivized quarterly provider knowledge assessment on compliance with Integrated Management of Childhood Illness (IMCI) protocols in Congo, DRC. Methods: Out of a total of 1738 facilities currently receiving results-based financing under an ongoing health financing program, 110 facilities were chosen for this study. All health care workers providing outpatient services to children under age 5 in these facilities will be included in the study. Facilities were randomized with equal probability to control and treatment. Treatment facilities will receive quarterly medical staff knowledge assessments using interactive vignettes. Performance on these vignettes will be rewarded through financial bonus payments to facilities. A baseline survey of health worker knowledge was conducted in 2018. An endline assessment is scheduled to start in the second half of 2021. The primary outcome of interest is health worker compliance with Integrated Management of Childhood Illness (IMCI) guidelines. Compliance will be verified through direct observation of medical staff-patient interactions. Discussion: This is to our knowledge the first trial assessing whether linking health financing to health care worker performance on knowledge assessments can increase compliance with under-5 case management protocols.