Abt Associates Inc.  In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane University’s School of Public Health Training Resources Group

Catalyzing Maternal and Child Health Results by Paying for Performance: Evidence from Developing Countries

Catherine Connor and Rena Eichler

Health Systems 20/20 Project15 November 2010Health Systems Research Symposium

What does pay for performance have to do with reaching universal coverage?

Feasibility of Insurance Design and Implementation

Monitoring and Evaluation

Financing

options

Benefits

package

Pop Covera

ge

Opera-tions

Organiza-

tional structur

e

Provider

engage-ment

Incentives to use priority

services

Pay providers for quality or

efficiency

Incentives to cover hard-to-reach populations

Presentation Objectives

What is Pay for Performance?

Highlights from on-line survey of country experiences

Expanding access for maternal and child health results: the case of Burundi

What we mean by P4P

Funds, Goods, Other

PayerDonars. Govenment, NGOs Health Programs, Insurers

RecipientPatients or Families

Service Providers (facility or health worker) NGO or program implementerGovernment - Local or National

Results

Demand Side

Supply Side

What is P4P?

Many terms: results-based financing, performance-based financing, performance-based contracting, conditional cash transfers, …

One common definition: “Transfer of money or material goods conditional

on taking a measurable health related action or achieving a predetermined performance target” *

*From the Center for Global Development Working Group on Performance-Based Incentives

Pay-for-Performance (P4P)An explosion of interest and funding

Flat salaries for providers leads to low incentives to provide quantity or quality or to serve the poor

Fixing incentives is important complement to infrastructure, technical, and capacity building interventions

P4P can be combined with any provider payment method: Salary, FFS, capitation, case-based, global budget

Why is P4P getting so much attention?

Snapshot of P4P Country Survey

Why do this survey? To fill the gap between growing

experimentation and little documentation

Global online survey 2009 90 e-responses 25 responses summarized

14 longer case studies in 2010

Distribution of 25 cases by region

Africa Asia Latin American and the Caribbean

Europe and Eurasia

Middle East

Benin Burundi (2) DRC(2)EthiopiaGhana Kenya (3, 1) RwandaTanzaniaUgandaZambia

Bangladesh Cambodia (2) IndiaPhilippines

BelizeBrazilHonduras

Armenia Egypt

15 5 3 1 1

Survey results: Purchasing focused on priority services

Maternal health results dominate (22/25). Child health results also top priority (14/25). Infectious (e.g. HIV/AIDS, malaria) and non-

communicable diseases (e.g. cancer screening, diabetes and asthma management) included but less frequent

Primary care facilities Rural or peri-urban areasCommunity outreachDemand side (users/patients) - vouchers and

transportation subsidies Increasing attempts to reward quality

Survey results: Designs to expand access

BURUNDI

Public-private purchasing to increase use of priority services and improve quality

What drove interest in PBF in Burundi?

Facility use rate (consults/year/person) 1 0.47 (2004)

Births attended by qualified staff1 9.8% (2004)

DTP3 immunization1 54% (2004)

Measles immunization1 50% (2004)

Contraceptive prevalence rate2 9% (2005)

U5 sleeping under insecticide-treated net2 8% (2005)

1. Kaneza 2007; 2.http://healthsystems2020.healthsystemsdatabase.org/

MoFDonors

ProvincialPurchasing

Agency

Health Facilities

$

$Facilities

report utilization

each month

Monthly payments fee for service

+ quarterly bonus for

quality

TechnicalAssistance

HealthNetTPOCordaid

P4P Purchasing – how it works

QualityAssess

Community survey

Family Planning

0200400600800

1000

months

Fig

ure

s

Target 2006 2007 2008

Number of women using contraceptive methods doubles

Burundi Results – Kibuye Province

Using P4P to expand access in developing countries

Many different designs Focus on maternal and child health Majority are supply-side (provider) Some are demand-side (user) Clear need for more documentation to learn what is

working and learn how design and implementation challenges are being overcome

Abt Associates Inc.  In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane University’s School of Public Health Training Resources Group

Thank you

Reports related to this presentation are available at www.HS2020.org