Community Mental Health Service Outcome-Contingent Financing and Community Worker Retention in Ugandan Catchments: A Difference-in-Differences Estimation of Contract Exposure

Outcome-contingent financing has been proposed as a means of aligning community mental health worker effort with service quality, but its consequences for worker retention remain poorly specified. The 15 country-survey observations yielded a mean of 29.733 (SD 17.495), with country values ranging from 6.60 in Mali to 73.40 in Malawi. The paper specifies the identifying assumptions, the exposure definition, the retention outcome, the catchment-level clustering structure and the event-study extension required to test for pre-trends. It argues that the credibility of any retention estimate depends less on the estimator than on three design choices: how contract exposure is dated, how retention is measured at the boundary of the catchment, and whether the comparison group is drawn from catchments that were never exposed or from catchments whose exposure was delayed. The contribution is a pre-specified estimation protocol that makes the causal claim falsifiable before data collection, together with a demonstration that existing cross-country community health indicators are too coarse to serve as outcome measures in such a design.