On World TB Day, Madhu Viswanathan, Associate Professor of Marketing and Research Director, ISB Institute of Data Science, Indian School of Business; Raghuram Bommaraju, Senior Assistant Professor of Marketing, Indian School of Business and Ridhima Sodhi, public health professional explains how salesforce model to improve private sector engagement can be a winning formula against TB
India has the highest burden of Tuberculosis in the world, accounting for one-fourth of global TB cases in 2021. It is estimated that around 60 per cent of TB patients in India seek care in the private sector but only around 30 per cent of these get notified to the national TB elimination programme (NTEP). Beyond providing an accurate estimate of the disease burden, notifications also play a key role in identifying patients and their providers and extending support and benefits to them such as access to free diagnosis and medication and cash transfers for nutritional support.
However, engaging with large number of private providers in India’s fragmented health system may require innovative approaches beyond those typically employed in public health settings. One such approach may be the field salesforce model routinely used by the pharma industry to increase awareness of their products among physicians and increase revenue. Of course, the applicability of such a model, where individual salespeople set revenue targets and are monetarily incentivised to meet those targets, is not well understood.
We used data from a large-scale private sector engagement project supported by the Government of India and funded by the Global Fund called Joint Effort for Elimination of TB (JEET) to assess the effectiveness of this model. As part of JEET, a consortium of three not-for-profit implementing agencies (FIND, WJCF and CHRI) were tasked with identifying 1.6 million TB cases over three years from over 400 districts across the country. These agencies employed a salesforce model to engage with the private providers and increase TB notifications. However, setting targets for individual salesperson was challenging due to lack of good quality data on the existing disease burden and, consequently, potential number of TB cases that a salesperson could find from his/her district.
Different agencies attempted to overcome this challenge using a variety of salesforce compensation models. One agency employed a group compensation plan whereas the other provided fixed compensation without any incentives which was combined with intensive auditing of the performance of salespeople by their managers. We exploited this variation as a quasi-experimental setup to study the cause-and-effect relationship between compensation plans and notifications which yielded important findings.
First, we found that salesforce model is effective in increasing case notifications, therefore contributing to public health outcomes. Second, we discovered that both group incentive and fixed compensation work significantly better than individual incentives while entering a new geography (resulting in more than 80 per cent increase in notifications). This finding that group incentive is equally effective while entering new geography is surprising as compensation literature from the corporate world favours only fixed plans when entering regions with high uncertainty. Further, once a geography was established, a switch to individual incentives from a group incentive plan was shown to improve performance by over 50 per cent.
We complemented the above analysis by conducting a survey of salespeople to understand the intrinsic and extrinsic motivations behind their efforts. We found salespeople from the fixed salary group had extensive NGO background and therefore identified themselves more as social workers. Salespeople from the incentives group (individual and group incentives) had substantial pharmaceutical sales background and were motivated by incentives rather than identifying themselves with a social cause. Moreover, 57 per cent of salespeople from the incentives group preferred individual incentives over group incentives. Such differences may impact the behaviour and efforts of people in performing different tasks, and hints at including elements in compensation plans that account for these differences.
These findings have the potential to inform wider public health initiatives, beyond the TB context, where new models of private sector engagement are required to improve public health outcomes. Organisations that rely on external funding and where attracting high quality human resources can be a challenge due to low salary bands, such insights into incentive plans can be useful for planning and strategising to achieve desired outcomes. For instance, using a group incentive structure would help reduce the pressure on individuals in uncertain territories and retain them, while obtaining optimal work at the group level. Similarly, once the salespeople become familiar with their regions, individual incentives may become more appealing. Having multiple components in the compensation plan such as financial incentives and non-financial recognition may help address the differences in motivation of salespeople coming from different backgrounds.