Using pay for performance incentives (P4P) to improve management of suspected malaria fevers in rural Kenya: a cluster randomized controlled trial

Authors: Diana Menya, Alyssa Platt, Imran Manji, Edna Sang, Rebeccah Wafula, Jing Ren, Olympia Cheruiyot, Janice Armstrong, Brian Neelon and Wendy Prudhomme O’Meara



Inappropriate treatment of non-malaria fevers with artemisinin-based combination therapies (ACTs) is a growing concern, particularly in light of emerging artemisinin resistance, but it is a behavior that has proven difficult to change. Pay for performance (P4P) programs have generated interest as a mechanism to improve health service delivery and accountability in resource-constrained health systems. However, there has been little experimental evidence to establish the effectiveness of P4P in developing countries. We tested a P4P strategy that emphasized parasitological diagnosis and appropriate treatment of suspected malaria, in particular reduction of unnecessary consumption of ACTs.


A random sample of 18 health centers was selected and received a refresher workshop on malaria case management. Pre-intervention baseline data was collected from August to September 2012. Facilities were subsequently randomized to either the comparison (n = 9) or intervention arm (n = 9). Between October 2012 and November 2013, facilities in the intervention arm received quarterly incentive payments based on seven performance indicators. Incentives were for use by facilities rather than as payments to individual providers. All non-pregnant patients older than 1 year of age who presented to a participating facility and received either a malaria test or artemether-lumefantrine (AL) were eligible to be included in the analysis. Our primary outcome was prescription of AL to patients with a negative malaria diagnostic test (n = 11,953). Our secondary outcomes were prescription of AL to patients with laboratory-confirmed malaria (n = 2,993) and prescription of AL to patients without a malaria diagnostic test (analyzed at the cluster level, n = 178 facility-months).


In the final quarter of the intervention period, the proportion of malaria-negative patients in the intervention arm who received AL was lower than in the comparison arm (7.3 % versus 10.9 %). The improvement from baseline to quarter 4 in the intervention arm was nearly three times that of the comparison arm (ratio of adjusted odds ratios for baseline to quarter 4 = 0.36, 95 % CI: 0.24–0.57). The rate of prescription of AL to patients without a test was five times lower in the intervention arm (adjusted incidence rate ratio = 0.18, 95 % CI: 0.07–0.48). Prescription of AL to patients with confirmed infection was not significantly different between the groups over the study period.


Facility-based incentives coupled with training may be more effective than training alone and could complement other quality improvement approaches.

Citation: Diana Menya, Alyssa Platt, Imran Manji, Edna Sang, Rebeccah Wafula, et al.BMC Medicine 2015, 13:268  doi:10.1186/s12916-015-0497-y

Received: 6 June 2015;    Accepted: 24 September 2015;   Published: 16 October 2015

Copyright: © 2015 Menya et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Competing interests

The authors declare that they have no competing interests.

Authors’ Contributions

DM, IM, JA, BN and WPO designed the study. AP, BN, RW and WPO analyzed the study results. All authors contributed to execution of the study, interpretation of results, preparation and critical review of the manuscript. WPO prepared the first draft of the manuscript. The funders had no role in the study design, the data collection, analysis and interpretation, the writing of the report, nor the decision to submit the article for publication.


Special appreciation goes to the district team members who facilitated the study: Angeline Aboto; Musa Chesire; David Cheruiyot; Rebecca Matalanga; Constance Were; and Caroline Wamalwa. We also thank the District Medical Officers of Health of Eldoret West, Keiyo, Baringo, Bungoma East, Teso North, Butula and Bunyala, as well as the Provincial Health Management Teams of former Rift Valley and Western Provinces for their support. We are grateful for the support of the Malaria Control Unit, Kenya. Finally, without the participation of all the facilities this study would not have been possible; our sincere appreciation to all the nurses, clinical officers and the laboratory staff.


Research reported in this publication was supported by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health under award number R21 AI095979 to WPO. The content is solely the responsibility of the authors and does not necessarily reflect the official views of the National Institutes of Health.