April 7, 2011

Alex Ergo, PhDBroad Branch Associates

Using Performance-Based Incentives to Enhance the Quality of MNCH Interventions in Developing Countries

The Maternal and Child Health Integrated Program (MCHIP)

USAID Bureau for Global Health’s flagship maternal, newborn and child health program

Working in well over 30 countries worldwide

MCHIP supports programming and opportunities for integration in: Maternal, Newborn and Child Health Immunization, Family Planning, Malaria,

HIV/AIDS Water & Sanitation, Urban Health, Health

Systems Strengthening

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Outline

Performance-based incentives (PBI): concept

PBI in developing countries: quick overview

Incentivizing quality of care: how?

What can we learn from high-income countries?

Performance-Based Incentives (PBI):An Umbrella Term

“Any program that rewards the delivery of one or more outputs or outcomes by one or more incentives, financial or otherwise, upon verification that the agreed-upon result has actually been delivered.”

Musgrove, Rewards for Good Performance or Results:A Short Glossary

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“Business as usual” is not enough

PBI: A Paradigm Shift in Global Health

Paying for andtracking inputs

Verifying and paying for results

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PBI is more than a financing mechanism

It is a powerful tool to strengthen health systems

PBI: A Paradigm Shift in Global Health

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Performance-Based AidPayments to national governments conditional on increasing health outputs or achieving impact

Supply-Side IncentivesPayments to sub-national levels of government, facilities, teams of health workers, or individual providers, conditional on increasing health outputs or outcomes

Demand-Side IncentivesPayments to communities, households or individuals, conditional on engaging in pre-agreed healthy behaviors

PBI Can Take Many Forms

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Payments to sub-national levels of government

e.g. Argentina, Benin, Burundi, Rwanda, Senegal, Tanzania, Zambia

Payments to facilities, or teams of health workers

e.g. Belize, Benin, Burundi, Egypt, Honduras, Rwanda, Senegal, Tanzania, Zambia

Payments to service delivery NGOse.g. Afghanistan, DRC, Haiti, Liberia, South Sudan

On the Supply Side

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Payments to individuals or households conditional on pre-agreed healthy behaviors

e.g. Brazil, Colombia, Mexico, Nicaragua, Tanzania Vouchers given or sold to individuals

redeemable for particular servicese.g. Bangladesh, Kenya, Nepal, Pakistan, Uganda

Incentives to TB patients for adhering to treatment regimen

e.g. Russia, US

On the Demand Side

Potential Health Impact

Large scope for increasing utilization AND improving quality in many areas

Immunization Nutrition Effective antenatal care Safe deliveries Family planning Malaria prevention and treatment TB detection and treatment HIV prevention and treatment

…But Many Implementation Challenges

Weak health information systems Dysfunctional supply chains Poor management capacity at all levels Truly independent external verifiers rare and

costly Shortage of well-trained human resources Sustainability – Concerns about how to pay for

implementation and financial incentives

PBI itself may help address some of these challenges

Quality of Care - Definition

“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

US Institute of Medicine

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Incentivizing Quality of Care: How?

Different countries/schemes take different approaches: Incentives linked to the achievement of

accreditation Incentives linked to improvements in scores on

quality assessment tools

Incentives linked to adherence to treatment (demand) or treatment protocols (supply)

Incentives linked to ‘quantity’ indicators reflecting a certain level of quality

Quality of Care as a carrot or as a stick

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Can We Learn From High-Income Countries?

The environments differ in some aspects: Low- and middle-income countries: under-

utilization of even the most basic services High-income countries: over-utilization of

highly specialized services

But they are surprisingly similar in other aspects:

Wide variations in how providers treat a same diagnosis: poor adherence to standard treatment guidelines

Under-utilization of preventive services

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What all countries have in common:

Increased emphasis on incentivizing quality of care

Can We Learn From High-Income Countries?

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Incentivizing quality of care in high-income countries – tendency: Incentives linked to maintaining population

healthywhile avoiding preventable hospitalization andemergency servicese.g. Accountable Care Organizations in the US

Incentives linked to reductions in unnecessary hospital admissions e.g. by refusing to pay for hospital re-admissions

What Can We Learn From High-Income Countries?

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Incentivizing quality of care is a dynamic process that needs continuous reengineering

Smart use of information technology might be a powerful driver

Incentives should promote a better coordination between the different levels of care / types of providers

Importance of being able to demonstrate what works, how and when

What Can We Learn From High-Income Countries?

For More Information…

www.RBFhealth.org

www.HealthSystems2020.org

http://www.cgdev.org/section/initiatives/_active/ghprn/workinggroups/performance

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Thank you!

wwww.mchip.net

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