What does it take to design digitally enabled performance management and incentive interventions for community health programs: Lessons from Ethiopia.

Abstract

The Health Extension Program (HEP) in Ethiopia has faced multifaceted challenges, including declining motivation and suboptimal performance of Health Extension Workers (HEWs). These issues have significantly impacted Reproductive, Maternal, Newborn, and Child Health (RMNCH) outcomes. To address these gaps, JSI, in collaboration with key partners, designed digitally enabled performance management (PM) and performance-based incentive (PBI) interventions integrated into the electronic Community Health Information System (eCHIS). A multi-approach design process was implemented, including a landscape review of existing strategies, human-centered design (HCD), and participatory co-design workshops. National and regional stakeholders contributed to the development process to ensure contextual relevance. A hybrid framework combining Management by Objectives (MBO) and the DESC (Digitally enabled, Equipped, Supervised, Compensated) model guided the design. The digitally enabled PM/PBI interventions required significant advancement to the eCHIS application suite, such as enhancing the existing focal person application (FPA) with real-time monitoring dashboards, digital target setting, and automated supervision features, and developing a national eCHIS dashboard for supervisory support, data-informed performance evaluation, and decision making. Twenty-two key performance indicators (KPIs) were identified to measure outputs, health outcomes, and supervisory processes. The intervention integrated digitally supported supervision and mentorship to drive performance improvements. Stakeholders proposed incentivizing the HEWs, supervisors, and HPs who record high performance biannually as a team and/or an individual with non-financial or mixed incentives. In conclusion, the participatory design process resulted in robust, scalable PM/PBI interventions tailored to Ethiopia's HEP. Digitally enabled tools, when aligned with supportive supervision and sustainable incentive strategies, have the potential to improve HEW motivation, RMNCH outcomes, and health system accountability. This model offers valuable lessons for other low-resource settings implementing performance management systems in community health programs.