Workload and team performance in health care: Evidence from Kenya

Heavy workloads facing health care providers may lead to changes in care processes that, in turn, affect quality of care and patient outcomes. Using direct observations of vaginal deliveries in three high-volume Kenyan hospitals, we study how workload affects care in maternity wards - a high-stress environment where hard-to-schedule patient admissions and uncertainty around labor progression can result in unexpected fluctuations in workload throughout the day. We first document that these facilities are persistently understaffed relative to international staffing benchmarks, implying high baseline workloads. Exploiting short-run variations in provider workload in this environment, we find that workload has little to no effect on quality, as measured by provider adherence to clinical guidelines and disrespectful care. We show that coping strategies employed by providers, such as using clinical interventions to speed up labor and delegating tasks to less qualified team members, may have weakened the relationship between workload and the quality measures we examine. However, these coping mechanisms could have negative implications for other (unmeasured) aspects of quality. Drawing on anecdotal and other evidence, we propose additional hypotheses for why quality may not be sensitive to workload in this setting.