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Performance of health providers:

a common objective, diverse strategies

Jean Perrot

WHO

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Performance:

• In developing countries it's mainly about increasing provider activity (quantitatively and qualitatively)

• In developed countries it's mainly about insuring a correct (efficient) use of resources

• We are not talking here about health system performance but health provider performance (micro level point of view)

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Contracting

Regulation

Result and Performance

Incentives

Strategy Tool Objective

Performance

Sanctions

Values

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The general model is indeed this:

• Increasing the performance of health service providers is always the objective

• The usual strategies that rely on sanctions or the respect of certain values (professional consciousness and values, etc.) yield only modest results

• Resorting to incentives is a new strategy

• Implementation of this strategy will make use of contractual or regulatory tools

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Result and Performance

InputsPredefined result

orMaximize result

Use of incentives

Rwanda model

Attribution of incentives

ContractingRegulation

ContractingRegulation

Step 1

Step 2

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In the "Rwanda model":

• Step 1: Criteria for attributing incentives rely on results, maximizing results. Bonus. Contract for a commitment to purchase

• Step 2: Use of the bonus focuses on inputs - top ups for staff who are thus motivated to increase the institution's results. This step is not included in the provider performance contract

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Result and Performance

Inputs Result

Attribution and use ofincentives

Mali Hospital Model

ContractingRegulation

Steps 1 et 2

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In the "Mali – hospital model":

• The results are not linked to the incentives

• Step 1: The criteria for attributing incentives focus on inputs, changes in behavior and practices of actors in institutions

• Step 2: Use of the bonus focuses on inputs (collective use); underlying hypothesis is that these changes in behavior will influence the results. This step is taken into account in the performance contract with providers

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• There is a profound change of rationale

• Political acceptation, labour unions, … in the society

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• Some important points:• Need to have financial resources for the activity: project approach is easier than general budget support

• Never forget that the actors have different interests: opportunistic behaviour: gaming, dumping

• Institutional performance – hypothesis of the need to incite the individuals; complex systems such as hospitals

• Artificial change of behaviour: not acting on the causes • Effect of taking things for granted• What is the part of the performance linked payments in the provider's

budget ? Inclusion of all the activities or just a few (prioritizing)

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Messages:

. Avoid thinking that there is only one way of doing things

For example, better to reward progress than results

. The role of development partners is important: - They often initiate the activities

- One can push but not impose; one should not give up too soon

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Key messages:

Performance based payment should not be regarded as a simple reward system that mechanically produces changes for the health workers, but as platform for a process of modifying practices