Is SMART the new stupid? Health worker perspectives on producing PBF indicators

Abstract

PBF program designers have traditionally selected and priced service delivery indicators based on public health value, and whether the indicator is SMART (specific, measurable, achievable, relevant, and timely). This approach ignores the providers perspective on the value of inputs and opportunity costs of service provision. We conducted in-depth interviews, focus group discussions, and rank order exercises with health workers to elucidate factors that drive their motivation to deliver PBF incentivized services. Health workers identified three key considerations that drive service prioritization: effort to acquire a patient, effort to treat a patient, and health worker locus of control. Health workers consider multiple factors when prioritizing PBF services to maximize their total reward. In pricing PBF services, program designers must understand inputs’ value and total opportunity costs, rather than relying on public health value and the SMART indicator framework alone. When pricing services, PBF program designers should collaborate with health workers to account for the range of factors that health workers consider when alone. When pricing services, PBF program designers should collaborate with health workers to account for the range of factors that health workers consider when making service provision decisions.