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Adamu AA, Jalo RI, Muhammad ID, Essoh TA, Ndwandwe D, Wiysonge CS. Sustainable financing for vaccination towards advancing universal health coverage in the WHO African region: The strategic role of national health insurance. Hum Vaccin Immunother 2024; 20:2320505. [PMID: 38414114 PMCID: PMC10903629 DOI: 10.1080/21645515.2024.2320505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/15/2024] [Indexed: 02/29/2024] Open
Abstract
There is a growing political interest in health reforms in Africa, and many countries are choosing national health insurance as their main financing mechanism for universal health coverage. Although vaccination is an essential health service that can influence progress toward universal health coverage, it is not often prioritized by these national health insurance systems. This paper highlights the potential gains of integrating vaccination into the package of health services that is provided through national health insurance and recommends practical policy actions that can enable countries to harness these benefits at population level.
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Affiliation(s)
- Abdu A. Adamu
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rabiu I. Jalo
- Department of Community Medicine, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Ibrahim D. Muhammad
- Department of Obstetrics and Gynecology, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Téné-Alima Essoh
- Agence de Médecine Préventive, Regional Office for Africa, Abidjan, Cote d’Ivoire
| | - Duduzile Ndwandwe
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Charles S. Wiysonge
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Vaccine-Preventable Diseases Programme, World Health Organization Regional Office for Africa, Brazzaville, Congo
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Fardousi N, Dantas Gurgel Junior G, Shimizu H, Silene de Brito E Silva K, Da Silva E, Dos Santos MOS, Falangola Benjamin Bezerra A, Gomes L, Powell-Jackson T, Sampaio J, Borghi J. Understanding the municipal-level design and adaptation of pay-for-performance schemes across two states of Brazil. Health Policy Plan 2024; 39:661-673. [PMID: 38706154 PMCID: PMC11308603 DOI: 10.1093/heapol/czae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/27/2024] [Accepted: 04/28/2024] [Indexed: 05/07/2024] Open
Abstract
The design of complex health systems interventions, such as pay for performance (P4P), can be critical to determining such programmes' success. In P4P programmes, the design of financial incentives is crucial in shaping how these programmes work. However, the design of such schemes is usually homogenous across providers within a given scheme. Consequently, there is a limited understanding of the strengths and weaknesses of P4P design elements from the implementers' perspective. This study takes advantage of the unique context of Brazil, where municipalities adapted the federal incentive design, resulting in variations in incentive design across municipalities. The study aims to understand why municipalities in Brazil chose certain P4P design features, the associated challenges and the local adaptations made to address problems in scheme design. This study was a multiple case study design relying on qualitative data from 20 municipalities from two states in Northeastern Brazil. We conducted two key informant interviews with municipal-level stakeholders and focus group discussions with primary care providers. We also reviewed municipal Primary Care Access and Quality laws in each municipality. We found substantial variation in the design choices made by municipalities regarding 'who was incentivized', the 'payment size' and 'frequency'. Design choices affected relationships within municipalities and within teams. Challenges were chiefly associated with fairness relating to 'who received the incentive', 'what is incentivized' and the 'incentive size'. Adaptations were made to improve fairness, mostly in response to pressure from the healthcare workers. The significant variation in design choices across municipalities and providers' response to them highlights the importance of considering local context in the design and implementation of P4P schemes and ensuring flexibility to accommodate local preferences and emerging needs. Attention is needed to ensure that the choice of 'who is incentivized' and the 'size of incentives' are inclusive and fair and the allocation and 'use of funds' are transparent.
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Affiliation(s)
- Nasser Fardousi
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
| | | | | | | | | | | | | | - Luciano Gomes
- Department of Health Promotion, Federal University of Paraíba, João Pessoa, Paraíba 58051-900, Brazil
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
| | - Juliana Sampaio
- Department of Health Promotion, Federal University of Paraíba, João Pessoa, Paraíba 58051-900, Brazil
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
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Russo LX, Powell-Jackson T, Borghi J, Sampaio J, Gurgel Junior GD, Shimizu HE, Bezerra AFB, E Silva KSDB, Barreto JOM, de Carvalho ALB, Kovacs RJ, Gomes LB, Fardousi N, da Silva EN. Does pay-for-performance design matter? Evidence from Brazil. Health Policy Plan 2024; 39:593-602. [PMID: 38661300 PMCID: PMC11145906 DOI: 10.1093/heapol/czae025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 02/14/2024] [Accepted: 04/23/2024] [Indexed: 04/26/2024] Open
Abstract
Pay-for-performance (P4P) schemes have been shown to have mixed effects on health care outcomes. A challenge in interpreting this evidence is that P4P is often considered a homogenous intervention, when in practice schemes vary widely in their design. Our study contributes to this literature by providing a detailed depiction of incentive design across municipalities within a national P4P scheme in Brazil [Primary Care Access and Quality (PMAQ)] and exploring the association of alternative design typologies with the performance of primary health care providers. We carried out a nation-wide survey of municipal health managers to characterize the scheme design, based on the size of the bonus, the providers incentivized and the frequency of payment. Using OLS regressions and controlling for municipality characteristics, we examined whether each design feature was associated with better family health team (FHT) performance. To capture potential interactions between design features, we used cluster analysis to group municipalities into five design typologies and then examined associations with quality of care. A majority of the municipalities included in our study used some of the PMAQ funds to provide bonuses to FHT workers, while the remaining municipalities spent the funds in the traditional way using input-based budgets. Frequent bonus payments (monthly) and higher size bonus allocations (share of 20-80%) were strongly associated with better team performance, while who within a team was eligible to receive bonuses did not in isolation appear to influence performance. The cluster analysis showed what combinations of design features were associated with better performance. The PMAQ score in the 'large bonus/many workers/high-frequency' cluster was 8.44 points higher than the 'no bonus' cluster, equivalent to a difference of 21.7% in the mean PMAQ score. Evidence from our study shows how design features can potentially influence health provider performance, informing the design of more effective P4P schemes.
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Affiliation(s)
- Letícia Xander Russo
- Faculty of Business, Accounting and Economics, Federal University of Grande Dourados, Rodovia Dourados—Itahum, Km 12, Dourados, MS 79804-970, Brazil
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1E 7HT, United Kingdom
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1E 7HT, United Kingdom
| | - Juliana Sampaio
- Department of Health Promotion, Federal University of Paraiba, João Pessoa 58051-900, Brazil
| | | | - Helena Eri Shimizu
- Department of Collective Health, University of Brasilia, Brasilia 70910-900, Brazil
| | | | - Keila Silene de Brito E Silva
- Collective Health Nucleous, Academic Center of Vitória, Federal University of Pernambuco, Vitória de Santo Antão 55608-680, Brazil
| | | | | | - Roxanne J Kovacs
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1E 7HT, United Kingdom
| | - Luciano Bezerra Gomes
- Department of Health Promotion, Federal University of Paraiba, João Pessoa 58051-900, Brazil
| | - Nasser Fardousi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1E 7HT, United Kingdom
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Zhang W, Li Y, Yuan B, Zhu D. Primary care providers' preferences for pay-for-performance programs: a discrete choice experiment study in Shandong China. HUMAN RESOURCES FOR HEALTH 2024; 22:20. [PMID: 38475844 DOI: 10.1186/s12960-024-00903-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/29/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Pay-for-performance (P4P) schemes are commonly used to incentivize primary healthcare (PHC) providers to improve the quality of care they deliver. However, the effectiveness of P4P schemes can vary depending on their design. In this study, we aimed to investigate the preferences of PHC providers for participating in P4P programs in a city in Shandong province, China. METHOD We conducted a discrete choice experiment (DCE) with 882 PHC providers, using six attributes: type of incentive, whom to incentivize, frequency of incentive, size of incentive, the domain of performance measurement, and release of performance results. Mixed logit models and latent class models were used for the statistical analyses. RESULTS Our results showed that PHC providers had a strong negative preference for fines compared to bonuses (- 1.91; 95%CI - 2.13 to - 1.69) and for annual incentive payments compared to monthly (- 1.37; 95%CI - 1.59 to - 1.14). Providers also showed negative preferences for incentive size of 60% of monthly income, group incentives, and non-release of performance results. On the other hand, an incentive size of 20% of monthly income and including quality of care in performance measures were preferred. We identified four distinct classes of providers with different preferences for P4P schemes. Class 2 and Class 3 valued most of the attributes differently, while Class 1 and Class 4 had a relatively small influence from most attributes. CONCLUSION P4P schemes that offer bonuses rather than fines, monthly rather than annual payments, incentive size of 20% of monthly income, paid to individuals, including quality of care in performance measures, and release of performance results are likely to be more effective in improving PHC performance. Our findings also highlight the importance of considering preference heterogeneity when designing P4P schemes.
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Affiliation(s)
- Wencai Zhang
- Dong Fureng Institute of Economic and Social Development, Wuhan University, Luojia Hill, Wuhan, 430072, China
| | - Yanping Li
- Economics and Management School, Wuhan University, Luojia Hill, Wuhan, 430072, China.
| | - BeiBei Yuan
- China Center for Health Development Studies, Peking University, No. 38 Yueyuan Road, Haidian District, Beijing, 100191, China
| | - Dawei Zhu
- China Center for Health Development Studies, Peking University, No. 38 Yueyuan Road, Haidian District, Beijing, 100191, China.
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, No. 38 Yueyuan Road, Haidian District, Beijing, 100191, China.
- International Research Center for Medicinal Administration (IRCMA), Peking University, No. 38 Yueyuan Road, Haidian District, Beijing, 100191, China.
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Al-Yateem N, Ahmad A, Subu MA, Ahmed F, Dias JM, Hijazi H, Rahman SA, Saifan AR. Hearing the voices of adolescents: Evaluating the quality of care for young adults with chronic illnesses in the UAE. J Pediatr Nurs 2023; 73:204-210. [PMID: 37804541 DOI: 10.1016/j.pedn.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND Quality care for adolescents and young adults with chronic illnesses has been under-explored in the United Arab Emirates (UAE) and internationally, especially from patients' perspectives. Most available international studies focused on quality of life and the transition to adulthood rather than service quality. AIM This research assesses care quality for adolescents with chronic illnesses in the UAE, aiming to understand their perspectives, appraise current practices, and identify service gaps. METHODS A cross-sectional survey employed a validated questionnaire examining 33 essential care components. Participants comprised 576 adolescents and young adults with chronic conditions from five UAE Emirates. RESULTS Participant's reports indicated that none of the 33 care elements were received consistently. Most participants (80.6%) reported crucial care aspects were absent, and across most investigated items, 19.4%-46.5% of participants reported receiving the services they were supposed to receive only some or many of the times, indicating significant areas for improvement. CONCLUSIONS Findings demonstrate significant care quality gaps for UAE's adolescents and young adults with chronic illnesses. These may critically affect their ability to manage their conditions and ensure holistic growth. These insights can guide healthcare enhancements tailored to this demographic. PRACTICE IMPLICATIONS There is an urgency for enhanced patient-centered care in UAE healthcare, emphasizing clinicians' roles in supporting adolescents with chronic illnesses, especially during transitions. Healthcare managers should prioritize standardized care policies, improved communication, and training that emphasizes consistent patient feedback and transition readiness. Further research into care gaps and tailored interventions within the region's distinct sociocultural setting is essential.
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Affiliation(s)
- Nabeel Al-Yateem
- Department of Nursing, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates; School of Nursing, Paramedicine and Healthcare Sciences, Faculty of Science and Health Charles Sturt University, ORANGE, NSW, Australia.
| | - Alaa Ahmad
- Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Muhamad Arsyad Subu
- Department of Nursing, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - Fatma Ahmed
- Department of Nursing, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates; Critical Care and Emergency Nursing Department, Faculty of Nursing, Alexandria University, Alexandria, Egypt
| | - Jacqueline Maria Dias
- Department of Nursing, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - Heba Hijazi
- Department of Health Service Administration, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates; Department of Health Management and Policy Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan
| | - Syed Azizur Rahman
- Department of Health Service Administration, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - Ahmad Rajeh Saifan
- Faculty of Nursing, Applied Sciences Private University, Amman, , Jordan
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Beiter D, Koy S, Flessa S. Improving the technical efficiency of public health centers in Cambodia: a two-stage data envelopment analysis. BMC Health Serv Res 2023; 23:912. [PMID: 37641129 PMCID: PMC10463960 DOI: 10.1186/s12913-023-09570-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 05/17/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Cambodia is undergoing a series of reforms with the objective of reaching universal health coverage. Information on the causes of inefficiencies in health facilities could pave the way for a better utilization of limited resources available to ensure the best possible health care for the population. OBJECTIVES The purpose of this study is to evaluate the technical efficiency of health centers and the determinants for inefficiencies. METHODS This cross-sectional study used secondary data from a costing study on 43 health centers in six Cambodian provinces (2016-2017). Firstly, the Data Envelopment Analysis method with output-orientation was applied to calculate efficiency scores by selecting multiple input and output variables. Secondly, a tobit regression was performed to analyze potential explanatory variables that could influence the inefficiency of health centers. RESULTS Study findings showed that 18 (43%) health centers were operating inefficiently with reference to the variable returns to scale efficiency frontier and had a mean pure technical efficiency score of 0.87. Overall, 22 (51%) revealed deficits in producing outputs at an optimal scale size. Distance to the next referral hospital, size and quality performance of the health centers were significantly correlated with health center inefficiencies. CONCLUSION Differences in efficiency exist among health centers in Cambodia. Inefficient health centers can improve their technical efficiency by increasing the utilization and quality of health services, even if it involves higher costs. Technical efficiency should be continuously monitored to observe changes in health center performance over time.
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Affiliation(s)
- Dominik Beiter
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh, Cambodia.
| | - Sokunthea Koy
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh, Cambodia
| | - Steffen Flessa
- Department of General Business Administration and Health Care Management, University of Greifswald, Greifswald, Germany
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Jamili S, Yousefi M, Pour HE, Houshmand E, Taghipour A, Tabatabaee SS, Adel A. Comparison of pay-for-performance (P4P) programs in primary care of selected countries: a comparative study. BMC Health Serv Res 2023; 23:865. [PMID: 37580717 PMCID: PMC10426118 DOI: 10.1186/s12913-023-09841-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/22/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Pay for performance (P4P) schemes provide financial incentives or facilities to health workers based on the achievement of predetermined performance goals. Various P4P programs have been implemented around the world. There is a question of which model is suitable for p4p implementation to achieve better results. The purpose of this study is to compare pay for performance models in different countries. METHODS This is a descriptive-comparative study comparing the P4P model in selected countries in 2022. Data for each country are collected from reliable databases and are tabulated to compare their payment models. the standard framework of the P4P model is used for data analysis. RESULTS we used the standard P4P model framework to compare pay for performance programs in the primary care sector of selected countries because this framework can demonstrate all the necessary features of payment programs, including performance domains and measures, basis for reward or penalty, nature of the reward or penalty, and data reporting. The results of this study show that although the principles of P4P are almost similar in the selected countries, the biggest difference is in the definition of performance domains and measures. CONCLUSIONS Designing an effective P4P program is very complex, and its success depends on a variety of factors, from the socioeconomic and cultural context and the healthcare goals of governments to the personal characteristics of the healthcare provider. considering these factors and the general framework of the features of P4P programs are critical to the success of the p4p design and implementation.
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Affiliation(s)
- Sara Jamili
- Student Research Committee, Department of Health Economics and Management Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mehdi Yousefi
- Department of Health Economics and Management, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Hossein Ebrahimi Pour
- Department of Health Economics and Management, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Elahe Houshmand
- Department of Health Economics and Management, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Taghipour
- Department of Epidemiology and Biostatistics, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Saeed Tabatabaee
- Department of Health Economics and Management, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amin Adel
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
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Han D, Clarke-Deelder E, Miller N, Opondo K, Burke T, Oguttu M, McConnell M, Cohen J. Health care provider decision-making and the quality of maternity care: An analysis of postpartum care in Kenyan hospitals. Soc Sci Med 2023; 331:116071. [PMID: 37450989 PMCID: PMC10410252 DOI: 10.1016/j.socscimed.2023.116071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/17/2023] [Accepted: 07/02/2023] [Indexed: 07/18/2023]
Abstract
Evidence suggests that health care providers' non-adherence to clinical guidelines is widespread and contributes to poor patient outcomes across low- and middle-income countries. Through observations of maternity care in Kenya, we found limited adherence to guideline-recommended active monitoring of patients for signs of postpartum hemorrhage, the leading cause of maternal mortality, despite providers' having the necessary training and equipment. Using survey vignettes conducted with 144 maternity providers, we documented evidence consistent with subjective risk and perceived uncertainty driving providers' decisions to actively monitor patients. Motivated by these findings, we introduced a simple model of providers' decision-making about whether to monitor a patient, which may depend on their perceptions of risk, diagnostic uncertainty, and the value of new information. The model highlights key trade-offs between gathering diagnostic information through active monitoring versus waiting for signs and symptoms of hemorrhage to manifest. Our work provides a template for understanding provider decision-making and could inform interventions to encourage more proactive obstetric care.
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Affiliation(s)
- Dan Han
- Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore; Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA.
| | - Emma Clarke-Deelder
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Epidemiology and Public Health, Swiss TPH and University of Basel, Basel, Switzerland
| | - Nora Miller
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Kennedy Opondo
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA; Kisumu Medical and Education Trust, Kisumu, Kenya
| | - Thomas Burke
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA; Global Health Innovation Laboratory, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | - Margaret McConnell
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Jessica Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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Tsai WC, Huang KH, Chen PC, Chang YC, Chen MS, Lee CB. Effects of individual and neighborhood social risks on diabetes pay-for-performance program under a single-payer health system. Soc Sci Med 2023; 326:115930. [PMID: 37146356 DOI: 10.1016/j.socscimed.2023.115930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 02/14/2023] [Accepted: 04/25/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Enrollment in and adherence to a diabetes pay-for-performance (P4P) program can lead to desirable processes and outcomes of diabetes care. However, knowledge is limited on the potential exclusion of patients with individual or neighborhood social risks or interruption of services in the disease-specific P4P program without mandatory participation under a single-payer health system. OBJECTIVE To investigate the impact of individual and neighborhood social risks on exclusion from and adherence to the diabetes P4P program of patients with type 2 diabetes (T2D) in Taiwan. METHODS This study used data from Taiwan's 2009-2017 population-based National Health Insurance Research Database, 2010 Population and Housing Census, and 2010 Income Tax Statistics. A retrospective cohort study was conducted, and study populations were identified from 2012 to 2014. The first cohort comprised 183,806 patients with newly diagnosed T2D, who had undergone follow up for 1 year; the second cohort consisted of 78,602 P4P patients who had undergone follow up for 2 years after P4P enrollment. Binary logistic regression models were used to examine the associations of social risks with exclusion from and adherence to the diabetes P4P program. RESULTS T2D patients with higher individual social risks were more likely to be excluded from the P4P program, but those with higher neighborhood-level social risks were slightly less likely to be excluded. T2D patients with the higher individual- or neighborhood-level social risks showed less likelihood of adhering to the program, and the person-level coefficient was stronger in magnitude than the neighborhood-level one. CONCLUSIONS Our results indicate the importance of individual social risk adjustment and special financial incentives in disease-specific P4P programs. Strategies for improving program adherence should consider individual and neighborhood social risks.
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Affiliation(s)
- Wen-Chen Tsai
- Department of Health Services Administration, College of Public Health, China Medical University, 100 Section 1, Jingmao Road, Beitun District, Taichung City, 406040, Taiwan
| | - Kuang-Hua Huang
- Department of Health Services Administration, College of Public Health, China Medical University, 100 Section 1, Jingmao Road, Beitun District, Taichung City, 406040, Taiwan
| | - Pei-Chun Chen
- International Master Program for Public Health, China Medical University, 100 Section 1, Jingmao Road, Beitun District, Taichung City, 406040, Taiwan
| | - Yu-Chia Chang
- Department of Long Term Care, National Quemoy University, 1 University Rd., Jinning Township, Kinmen County, 892009, Kinmen, Taiwan; Department of Healthcare Administration, Asia University, 500, Lioufeng Rd., Wufeng, Taichung City, 41354, Taiwan
| | - Michael S Chen
- Department of Social Welfare, National Chung Cheng University, 168 Section 1, University Rd., Minhsiung, Chiayi, 621301, Taiwan
| | - Chiachi Bonnie Lee
- Department of Health Services Administration, College of Public Health, China Medical University, 100 Section 1, Jingmao Road, Beitun District, Taichung City, 406040, Taiwan.
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Dantas Gurgel G, Kristensen SR, da Silva EN, Gomes LB, Barreto JOM, Kovacs RJ, Sampaio J, Bezerra AFB, de Brito E Silva KS, Shimizu HE, de Sousa ANA, Fardousi N, Borghi J, Powell-Jackson T. Pay-for-performance for primary health care in Brazil: A comparison with England's Quality Outcomes Framework and lessons for the future. Health Policy 2023; 128:62-68. [PMID: 36481068 DOI: 10.1016/j.healthpol.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/13/2022] [Accepted: 11/16/2022] [Indexed: 11/21/2022]
Abstract
Pay-for-performance (P4P) has been widely applied in OECD countries to improve the quality of both primary and secondary care, and is increasingly being implemented in low- and middle-income countries. In 2011, Brazil introduced one of the largest P4P schemes in the world, the National Programme for Improving Primary Care Access and Quality (PMAQ). We critically assess the design of PMAQ, drawing on a comparison with England's quality and outcome framework which, like PMAQ, was implemented at scale relatively rapidly within a nationalised health system. A key feature of PMAQ was that payment was based on the performance of primary care teams but rewards were given to municipalities, who had autonomy in how the funds could be used. This meant the incentives felt by family health teams were contingent on municipality decisions on whether to pass the funds on as bonuses and the basis upon which they allocated the funds between and within teams. Compared with England's P4P scheme, performance measurement under PMAQ focused more on structural rather than process quality of care, relied on many more indicators, and was less regular. While PMAQ represented an important new funding stream for primary health care, our review suggests that theoretical incentives generated were unclear and could have been better structured to direct health providers towards improvements in quality of care.
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Affiliation(s)
| | - Søren Rud Kristensen
- Institute of Global Health Innovation, Imperial College London, London, UK; Danish Centre for Health Economics, University of Southern Denmark, Odense, Denmark.
| | | | | | | | - Roxanne J Kovacs
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Juliana Sampaio
- Department of Health Promotion, Federal University of Paraiba, João Pessoa, Brazil.
| | | | | | - Helena Eri Shimizu
- Department of Collective Health, University of Brasilia, Brasilia, Brazil.
| | | | - Nasser Fardousi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
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Shaikh BT, Ali N. Universal health coverage in Pakistan: is the health system geared up to take on the challenge? Global Health 2023; 19:4. [PMID: 36635698 PMCID: PMC9836329 DOI: 10.1186/s12992-023-00904-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 12/30/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND There is a strong and wide consensus that Pakistan must pursue universal health coverage (UHC) attainment as the driving force for achieving sustainable development goals by 2030. Nevertheless, several institutional and socioeconomic challenges may hinder the progress toward UHC. MAIN BODY It is important that the health system of Pakistan must be transformed to strengthen all three dimensions of UHC i.e. maximizing the population covered, increasing the range of services offered, and reducing the cost-sharing. To make UHC dream a reality in Pakistan, there are some pre-requisites to meet upfront: a) budgetary allocation for health as percentage of GDP must be increased; b) health system's readiness especially in the public sector ought to improve in terms of human resource and availability of essential services; c) safety nets for health must continue regardless of the change in the political regimes; d) decrease the reliance on donors' funding; and e) accountability to be ensured across the board for service providers, managers, administrators and policymakers in the health system. CONCLUSION COVID-19 pandemic has revealed some major gaps in the health system's capacity to deliver equitable healthcare, which is a cornerstone to achieving the UHC agenda. The priority-setting process will need to be aligned with the SDGs to ensure that the agenda for action towards 2030 is comprehensively addressed and successfully accomplished preferably before, but hopefully not beyond the targeted dates.
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Affiliation(s)
- Babar Tasneem Shaikh
- JSI Research & Training Institute Inc, Mezzanine Floor, Grand Hotel, Street 1, MPCHS, E-11/1, Islamabad, 44000, Pakistan.
| | - Nabeela Ali
- JSI Research & Training Institute Inc, Mezzanine Floor, Grand Hotel, Street 1, MPCHS, E-11/1, Islamabad, 44000 Pakistan
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Koy S, Fuerst F, Tuot B, Starke M, Flessa S. The Flipped Break-Even: Re-Balancing Demand- and Supply-Side Financing of Health Centers in Cambodia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1228. [PMID: 36674006 PMCID: PMC9858853 DOI: 10.3390/ijerph20021228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 06/17/2023]
Abstract
Supply-side healthcare financing still dominates healthcare financing in many countries where the government provides line-item budgets for health facilities irrespective of the quantity or quality of services rendered. There is a risk that this approach will reduce the efficiency of services and the value of money for patients. This paper analyzes the situation of public health centers in Cambodia to determine the relevance of supply- and demand-side financing as well as lump sum and performance-based financing. Based on a sample of the provinces of Kampong Thom and Kampot in the year 2019, we determined the income and expenditure of each facility and computed the unit cost with comprehensive step-down costing. Furthermore, the National Quality Enhancement Monitoring Tool (NQEMT) provided us with a quality score for each facility. Finally, we calculated the efficiency as the quotient of quality and cost per service unit as well as correlations between the variables. The results show that the largest share of income was received from supply-side financing, i.e., the government supports the health centers with line-item budgets irrespective of the number of patients and the quality of care. This paper demonstrates that the efficiency of public health centers increases if the relevance of performance-based financing increases. Thus, the authors recommend increasing performance-based financing in Cambodia to improve value-based healthcare. There are several alternatives available to re-balance demand- and supply-side financing, and all of them must be thoroughly analyzed before they are implemented.
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Affiliation(s)
- Sokunthea Koy
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Franziska Fuerst
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Bunnareth Tuot
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Maurice Starke
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Steffen Flessa
- Department of Health Care Management, University of Greifswald, 17487 Greifswald, Germany
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Kabego L, Kourouma M, Ousman K, Baller A, Milambo JP, Kombe J, Houndjo B, Boni FE, Musafiri C, Molembo S, Kalumuna S, Tshongo M, Biringiro JN, Moke N, Kumutima C, Nkita J, Ngoma P, Azzouz C, Okum R, Yao M, Chamla D, Gueye AS, Fall IS. Impact of multimodal strategies including a pay for performance strategy in the improvement of infection prevention and control practices in healthcare facilities during an Ebola virus disease outbreak. BMC Infect Dis 2023; 23:12. [PMID: 36609234 PMCID: PMC9824906 DOI: 10.1186/s12879-022-07956-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 12/19/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Strategy to mitigate various Ebola virus disease (EVD) outbreaks are focusing on Infection Prevention and Control (IPC) capacity building, supportive supervision and IPC supply donation. This study was conducted to assess the impact of a Pay for Performance Strategy (PPS) in improving IPC performance in healthcare facilities (HF) in context of the 2018-2019 Nord Kivu/ Democratic Republic of the Congo EVD outbreak. METHODS A quasi-experimental study was conducted analysing the impact of a PPS on the IPC performance. HF were selected following the inclusion criteria upon informed consent from the facility manager and the National Department of Health. Initial and process assessment of IPC performance was conducted by integrating response teams using a validated IPC assessment tool for HF. A bundle of interventions was then implemented in the different HF including training of health workers, donation of IPC kits, supportive supervision during the implementation of IPC activities, and monetary reward. IPC practices in HF were assessment every two weeks during the intervention period to measure the impact. The IPC assessment tool had 34 questions aggregated in 8 different thematic areas: triage and isolation capacity, IPC committee in HF, hand hygiene, PPE, decontamination and sterilization, linen management, hospital environment and Waste management. Data were analysed using descriptive statistics and analytical approaches according to assumptions. R software (version 4.0.3) was used for all the analyses and a p-value of 0.05 was considered as the threshold for statistically significant results. RESULTS Among 69 HF involved in this study, 48 were private facilities and 21 state facilities. The median baseline IPC score was 44% (IQR: 21-65%); this IPC median score reached respectively after 2, 4, 6 and 8 weeks 68% (IQR: 59-76%), 79% (71-84%), 76% (68-85%) and 79% (74-85%). The improvement of IPC score was statistically significative. Spearman's rank-order correlation revealed the associated between proportion of trained HW and IPC score performance after 8 weeks of interventions (rs = .280, p-value = 0.02). CONCLUSION Pay for Performance Strategy was proved effective in improving healthcare facilities capacity in infection prevention and control practice in context of 2018 EVD outbreak in Nord Kivu. However, the strategy for long-term sustainability of IPC needs further provision. More studies are warranted on the HW and patients' perceptions toward IPC program implementation in context of Nord Kivu Province.
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Affiliation(s)
- Landry Kabego
- World Health Organization, Kinshasa, Democratic Republic of the Congo.
| | - Mamadou Kourouma
- World Health Organization, Kinshasa, Democratic Republic of the Congo
| | - Kevin Ousman
- World Health Organization, Kinshasa, Democratic Republic of the Congo
| | - April Baller
- World Health Organization, Kinshasa, Democratic Republic of the Congo
| | - Jean-Paul Milambo
- World Health Organization, Kinshasa, Democratic Republic of the Congo
| | - John Kombe
- Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Bienvenu Houndjo
- United Nations International Children’s Funds, Kinshasa, Democratic Republic of the Congo
| | - Franck Eric Boni
- United Nations International Children’s Funds, Kinshasa, Democratic Republic of the Congo
| | - Castro Musafiri
- Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Siya Molembo
- Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | | | - Moise Tshongo
- Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | | | - Nancy Moke
- Africa Centre for Disease Control, Kinshasa, Democratic Republic of the Congo
| | - Clarisse Kumutima
- Africa Centre for Disease Control, Kinshasa, Democratic Republic of the Congo
| | - Justin Nkita
- Africa Centre for Disease Control, Kinshasa, Democratic Republic of the Congo
| | - Polydor Ngoma
- Africa Centre for Disease Control, Kinshasa, Democratic Republic of the Congo
| | - Chedly Azzouz
- World Health Organization, Kinshasa, Democratic Republic of the Congo
| | - Raphaël Okum
- World Health Organization, Kinshasa, Democratic Republic of the Congo
| | - Michel Yao
- World Health Organization, Kinshasa, Democratic Republic of the Congo
| | - Dick Chamla
- World Health Organization, Kinshasa, Democratic Republic of the Congo
| | - Abdou Salam Gueye
- World Health Organization, Kinshasa, Democratic Republic of the Congo
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Fardousi N, Nunes da Silva E, Kovacs R, Borghi J, Barreto JOM, Kristensen SR, Sampaio J, Shimizu HE, Gomes LB, Russo LX, Gurgel GD, Powell-Jackson T. Performance bonuses and the quality of primary health care delivered by family health teams in Brazil: A difference-in-differences analysis. PLoS Med 2022; 19:e1004033. [PMID: 35797409 PMCID: PMC9262241 DOI: 10.1371/journal.pmed.1004033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 05/26/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pay-for-performance (P4P) programmes to incentivise health providers to improve quality of care have been widely implemented globally. Despite intuitive appeal, evidence on the effectiveness of P4P is mixed, potentially due to differences in how schemes are designed. We exploited municipality variation in the design features of Brazil's National Programme for Improving Primary Care Access and Quality (PMAQ) to examine whether performance bonuses given to family health team workers were associated with changes in the quality of care and whether the size of bonus mattered. METHODS AND FINDINGS For this quasi-experimental study, we used a difference-in-differences approach combined with matching. We compared changes over time in the quality of care delivered by family health teams between (bonus) municipalities that chose to use some or all of the PMAQ money to provide performance-related bonuses to team workers with (nonbonus) municipalities that invested the funds using traditional input-based budgets. The primary outcome was the PMAQ score, a quality of care index on a scale of 0 to 100, based on several hundred indicators (ranging from 598 to 660) of health care delivery. We did one-to-one matching of bonus municipalities to nonbonus municipalities based on baseline demographic and economic characteristics. On the matched sample, we used ordinary least squares regression to estimate the association of any bonus and size of bonus with the prepost change over time (between November 2011 and October 2015) in the PMAQ score. We performed subgroup analyses with respect to the local area income of the family health team. The matched analytical sample comprised 2,346 municipalities (1,173 nonbonus municipalities; 1,173 bonus municipalities), containing 10,275 family health teams that participated in PMAQ from the outset. Bonus municipalities were associated with a 4.6 (95% CI: 2.7 to 6.4; p < 0.001) percentage point increase in the PMAQ score compared with nonbonus municipalities. The association with quality of care increased with the size of bonus: the largest bonus group saw an improvement of 8.2 percentage points (95% CI: 6.2 to 10.2; p < 0.001) compared with the control. The subgroup analysis showed that the observed improvement in performance was most pronounced in the poorest two-fifths of localities. The limitations of the study include the potential for bias from unmeasured time-varying confounding and the fact that the PMAQ score has not been validated as a measure of quality of care. CONCLUSIONS Performance bonuses to family health team workers compared with traditional input-based budgets were associated with an improvement in the quality of care.
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Affiliation(s)
- Nasser Fardousi
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Roxanne Kovacs
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | - Juliana Sampaio
- Department of Health Promotion, Federal University of Paraiba, João Pessoa, Paraiba, Brazil
| | | | - Luciano B. Gomes
- Department of Health Promotion, Federal University of Paraiba, João Pessoa, Paraiba, Brazil
| | | | | | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
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Diaconu K, Witter S, Binyaruka P, Borghi J, Brown GW, Singh N, Herrera CA. Appraising pay-for-performance in healthcare in low- and middle-income countries through systematic reviews: reflections from two teams. Cochrane Database Syst Rev 2022; 5:ED000157. [PMID: 35593101 PMCID: PMC9121198 DOI: 10.1002/14651858.ed000157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | | | | | | | | | - Neha Singh
- London School of Hygiene & Tropical MedicineLondonUK
| | - Cristian A Herrera
- Department of Public HealthSchool of MedicinePontificia Universidad Católica de ChileChile
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Kovacs R, Brown GW, Kadungure A, Kristensen SR, Gwati G, Anselmi L, Midzi N, Borghi J. Who is Paid in Pay-For-Performance? Inequalities in the Distribution of Financial Bonuses Amongst Health Centres in Zimbabwe. Health Policy Plan 2022; 37:429-439. [PMID: 35090018 PMCID: PMC9006063 DOI: 10.1093/heapol/czab154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/08/2021] [Accepted: 01/28/2022] [Indexed: 11/25/2022] Open
Abstract
Although pay-for-performance (P4P) schemes have been implemented across low- and middle-income countries (LMICs), little is known about their distributional consequences. A key concern is that financial bonuses are primarily captured by providers who are already better able to perform (for example, those in wealthier areas), P4P could exacerbate existing inequalities within the health system. We examine inequalities in the distribution of pay-outs in Zimbabwe’s national P4P scheme (2014–2016) using quantitative data on bonus payments and facility characteristics and findings from a thematic policy review and 28 semi-structured interviews with stakeholders at all system levels. We found that in Zimbabwe, facilities with better baseline access to guidelines, more staff, higher consultation volumes and wealthier and less remote target populations earned significantly higher P4P bonuses throughout the programme. For instance, facilities that were 1 SD above the mean in terms of access to guidelines, earned 90 USD more per quarter than those that were 1 SD below the mean. Differences in bonus pay-outs for facilities that were 1 SD above and below the mean in terms of the number of staff and consultation volumes are even more pronounced at 348 USD and 445 USD per quarter. Similarly, facilities with villages in the poorest wealth quintile in their vicinity earned less than all others—and 752 USD less per quarter than those serving villages in the richest quintile. Qualitative data confirm these findings. Respondents identified facility baseline structural quality, leadership, catchment population size and remoteness as affecting performance in the scheme. Unequal distribution of P4P pay-outs was identified as having negative consequences on staff retention, absenteeism and motivation. Based on our findings and previous work, we provide some guidance to policymakers on how to design more equitable P4P schemes.
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Affiliation(s)
- Roxanne Kovacs
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Garrett W Brown
- School of Politics and International Studies (POLIS), University of Leeds, Woodhouse Leeds LS2 9JT, UK
| | | | - Søren R Kristensen
- Danish Centre for Health Economics University of Southern Denmark, 5000 Odense C Denmark & Imperial College London, Faculty of Medicine, Institute of Global Health Innovation, London SW7 2AZ, UK
| | - Gwati Gwati
- Ministry of Health and Child Care, Harare, Zimbabwe
| | - Laura Anselmi
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, M13 9NT, UK
| | - Nicholas Midzi
- National Institute of Health Research, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Josephine Borghi
- *Corresponding author. Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK. E-mail:
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Borghi J, Binyaruka P, Mayumana I, Lange S, Somville V, Maestad O. Long-term effects of payment for performance on maternal and child health outcomes: evidence from Tanzania. BMJ Glob Health 2021; 6:e006409. [PMID: 34916272 PMCID: PMC8679076 DOI: 10.1136/bmjgh-2021-006409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/24/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The success of payment for performance (P4P) schemes relies on their ability to generate sustainable changes in the behaviour of healthcare providers. This paper examines short-term and longer-term effects of P4P in Tanzania and the reasons for these changes. METHODS We conducted a controlled before and after study and an embedded process evaluation. Three rounds of facility, patient and household survey data (at baseline, after 13 months and at 36 months) measured programme effects in seven intervention districts and four comparison districts. We used linear difference-in-difference regression analysis to determine programme effects, and differential effects over time. Four rounds of qualitative data examined evolution in programme design, implementation and mechanisms of change. RESULTS Programme effects on the rate of institutional deliveries and antimalarial treatment during antenatal care reduced overtime, with stock out rates of antimalarials increasing over time to baseline levels. P4P led to sustained improvements in kindness during deliveries, with a wider set of improvements in patient experience of care in the longer term. A change in programme management and funding delayed incentive payments affecting performance on some indicators. The verification system became more integrated within routine systems over time, reducing the time burden on managers and health workers. Ongoing financial autonomy and supervision sustained motivational effects in those aspects of care giving not reliant on funding. CONCLUSION Our study adds to limited and mixed evidence documenting how P4P effects evolve over time. Our findings highlight the importance of undertaking ongoing assessment of effects over time.
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Affiliation(s)
- Josephine Borghi
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter Binyaruka
- Ifakara Health Institute, Dar es Salaam, Tanzania, United Republic of
- Chr Michelsen Institute, Bergen, Norway
| | - Iddy Mayumana
- Ifakara Health Institute, Ifakara, Morogoro, Tanzania, United Republic of
| | - Siri Lange
- Chr Michelsen Institute, Bergen, Norway
- Department of Health Promotion and Development, University of Bergen, Bergen, Hordaland, Norway
| | - Vincent Somville
- Chr Michelsen Institute, Bergen, Norway
- NHH Norwegian School of Economics, Bergen, Norway
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Gadsden T, Mabunda SA, Palagyi A, Maharani A, Sujarwoto S, Baddeley M, Jan S. Performance-based incentives and community health workers' outputs, a systematic review. Bull World Health Organ 2021; 99:805-818. [PMID: 34737473 PMCID: PMC8542270 DOI: 10.2471/blt.20.285218] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To review the evidence on the impact on measurable outcomes of performance-based incentives for community health workers (CHWs) in low- and middle-income countries. METHODS We conducted a systematic review of intervention studies published before November 2020 that evaluated the impact of financial and non-financial performance-based incentives for CHWs. Outcomes included patient health indicators; quality, utilization or delivery of health-care services; and CHW motivation or satisfaction. We assessed risk of bias for all included studies using the Cochrane tool. We based our narrative synthesis on a framework for measuring the performance of CHW programmes, comprising inputs, processes, performance outputs and health outcomes. FINDINGS Two reviewers screened 2811 records; we included 12 studies, 11 of which were randomized controlled trials and one a non-randomized trial. We found that non-financial, publicly displayed recognition of CHWs' efforts was effective in improved service delivery outcomes. While large financial incentives were more effective than small ones in bringing about improved performance, they often resulted in the reallocation of effort away from other, non-incentivized tasks. We found no studies that tested a combined package of financial and non-financial incentives. The rationale for the design of performance-based incentives or explanation of how incentives interacted with contextual factors were rarely reported. CONCLUSION Financial performance-based incentives alone can improve CHW service delivery outcomes, but at the risk of unincentivized tasks being neglected. As calls to professionalize CHW programmes gain momentum, research that explores the interactions among different forms of incentives, context and sustainability is needed.
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Affiliation(s)
- Thomas Gadsden
- The George Institute for Global Health, University of New South Wales, Sydney, Level 5/1 King St, Newtown 2042, New South Wales, Australia
| | - Sikhumbuzo A Mabunda
- The George Institute for Global Health, University of New South Wales, Sydney, Level 5/1 King St, Newtown 2042, New South Wales, Australia
| | - Anna Palagyi
- The George Institute for Global Health, University of New South Wales, Sydney, Level 5/1 King St, Newtown 2042, New South Wales, Australia
| | - Asri Maharani
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, England
| | - Sujarwoto Sujarwoto
- Department of Public Administration, University of Brawijaya, Malang, Indonesia
| | - Michelle Baddeley
- UTS Business School, University of Technology Sydney, Sydney, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Level 5/1 King St, Newtown 2042, New South Wales, Australia
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Khanna M, Loevinsohn B, Pradhan E, Fadeyibi O, McGee K, Odutolu O, Fritsche GB, Meribole E, Vermeersch CMJ, Kandpal E. Decentralized facility financing versus performance-based payments in primary health care: a large-scale randomized controlled trial in Nigeria. BMC Med 2021; 19:224. [PMID: 34544415 PMCID: PMC8452448 DOI: 10.1186/s12916-021-02092-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health system financing presents a challenge in many developing countries. We assessed two reform packages, performance-based financing (PBF) and direct facility financing (DFF), against each other and business-as-usual for maternal and child healthcare (MCH) provision in Nigeria. METHODS We sampled 571 facilities (269 in PBF; 302 in DFF) in 52 districts randomly assigned to PBF or DFF, and 215 facilities in 25 observable-matched control districts. PBF facilities received $2 ($1 for operating grants plus $1 for bonuses) for every $1 received by DFF facilities (operating grants alone). Both received autonomy, supervision, and enhanced community engagement, isolating the impact of additional performance-linked facility and health worker payments. Facilities and households with recent pregnancies in facility catchments were surveyed at baseline (2014) and endline (2017). Outcomes were Penta3 immunization, institutional deliveries, modern contraceptive prevalence rate (mCPR), four-plus antenatal care (ANC) visits, insecticide-treated mosquito net (ITN) use by under-fives, and directly observed quality of care (QOC). We estimated difference-in-differences with state fixed effects and clustered standard errors. RESULTS PBF increased institutional deliveries by 10% points over DFF and 7% over business-as-usual (p<0.01). PBF and DFF were more effective than business-as-usual for Penta3 (p<0.05 and p<0.01, respectively); PBF also for mCPR (p<0.05). Twenty-one of 26 QOC indicators improved in both PBF and DFF relative to business-as-usual (p<0.05). However, except for deliveries, PBF was as or less effective than DFF: Penta3 immunization and ITN use were each 6% less than DFF (p<0.1 for both) and QOC gains were also comparable. Utilization gains come from the middle of the rural wealth distribution (p<0.05). CONCLUSIONS Our findings show that both PBF and DFF represent significant improvements over business-as-usual for service provision and quality of care. However, except for institutional delivery, PBF and DFF do not differ from each other despite PBF disbursing $2 for every dollar disbursed by DFF. These findings highlight the importance of direct facility financing and decentralization in improving PHC and suggest potential complementarities between the two approaches in strengthening MCH service delivery. TRIAL REGISTRATION ClinicalTrials.gov NCT03890653 ; May 8, 2017. Retrospectively registered.
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Affiliation(s)
| | - Benjamin Loevinsohn
- The Global Fund, Global Health Campus, Chemin du Pommier 40, 1218 Grand-Saconnex, Geneva, Switzerland
| | - Elina Pradhan
- Health, Nutrition and Population, The World Bank, 1818 H Street NW, Washington, DC, 20433, USA
| | - Opeyemi Fadeyibi
- Health, Nutrition and Population, The World Bank, 102 Yakubu Gowon Cres, Asokoro, Abuja, Nigeria
| | - Kevin McGee
- Development Data Group, The World Bank, 1818 H Street NW, Washington, DC, 20433, USA
| | - Oluwole Odutolu
- Health, Nutrition and Population, The World Bank, 102 Yakubu Gowon Cres, Asokoro, Abuja, Nigeria
| | - Gyorgy Bela Fritsche
- Health, Nutrition and Population, The World Bank, 1818 H Street NW, Washington, DC, 20433, USA
| | - Emmanuel Meribole
- The Federal Ministry of Health of Nigeria, New Federal Secretariat Complex, Phase III, Ahmadu Bello Way, Central Business District, FCT, Abuja, Nigeria
| | - Christel M J Vermeersch
- Health, Nutrition and Population, The World Bank, 1818 H Street NW, Washington, DC, 20433, USA
| | - Eeshani Kandpal
- Development Data Group, The World Bank, 1818 H Street NW, Washington, DC, 20433, USA. .,Development Research Group, The World Bank, 1818 H Street NW, Washington, DC, 20433, USA.
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Fichera E, Anselmi L, Gwati G, Brown G, Kovacs R, Borghi J. Can Results-Based Financing improve health outcomes in resource poor settings? Evidence from Zimbabwe. Soc Sci Med 2021; 279:113959. [PMID: 33991792 PMCID: PMC8210646 DOI: 10.1016/j.socscimed.2021.113959] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/09/2021] [Accepted: 04/19/2021] [Indexed: 02/06/2023]
Abstract
Result Based Financing (RBF) has been implemented in health systems across low and middle-income countries (LMICs), with the objective of improving population health. Most evaluations of RBF schemes have focused on average programme effects for incentivised services. There is limited evidence on the potential effect of RBF on health outcomes, as well as on the heterogeneous effects across socio-economic groups and time periods. This study analyses the effect of Zimbabwe's national RBF scheme on neonatal, infant and under five mortality, using Demographic and Health Survey data from 2005, 2010 and 2015. We use a difference in differences design, which exploits the staggered roll-out of the scheme across 60 districts. We examine average programme effects and perform sub-group analyses to assess differences between socio-economic groups. We find that RBF reduced under-five mortality by two percentage points overall, but that this decrease was only significant for children of mothers with above median wealth (2.7 percentage points) and education (2.1 percentage points). RBF increased institutional delivery by seven percentage points – with a statistically significant effect for poorer socio-economic groups and least educated. We also find that RBF reduced c-section rates by three percentage points. We find no detectable effect of RBF on other incentivised services. When considering programme effects over time, we find that effects were only observed during the second phase of the programme (March 2012) with the exception of c-sections, which only reduced in the longer term. Further research is needed to examine whether these findings can be generalised to other settings. Zimbabwe's national Results Based Financing scheme decreased under-five mortality. Among higher wealth and education groups. RBF increased institutional deliveries in the poorest and least educated groups and reduced the rate of c-section. There were no programme effects on other incentivised services. The RBF programme effects generally appear to be stronger earlier in the implementation process.
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Affiliation(s)
- Eleonora Fichera
- Department of Economics, University of Bath, 2.11 - 3 East, Claverton Down Road, BA2 7AY, Bath, UK.
| | - Laura Anselmi
- Health, Organisation, Policy and Economics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, UK
| | - Gwati Gwati
- Zimbabwe Ministry of Health and Child Care, Zimbabwe
| | - Garrett Brown
- School of Politics and International Studies, University of Leeds, UK
| | - Roxanne Kovacs
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK
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21
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Explaining the Factors Affecting the Relative Value of Services and Their Role in the Performance-Based Payment System in Teaching-Therapeutic Centers in the Six national-Wide region of the Country. PREVENTIVE CARE IN NURSING AND MIDWIFERY JOURNAL 2021. [DOI: 10.52547/pcnm.11.2.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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22
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Amgalan N, Shin JS, Lee SH, Badamdorj O, Ravjir O, Yoon HB. The socio-economic transition and health professions education in Mongolia: a qualitative study. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:16. [PMID: 33678178 PMCID: PMC7938553 DOI: 10.1186/s12962-021-00269-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 02/26/2021] [Indexed: 11/10/2022] Open
Abstract
Background Former socialist countries have undergone a socio-economic transition in recent decades. New challenges for the healthcare system have arisen in the transition economy, leading to demands for better management and development of the health professions. However, few studies have explored the effects of this transition on health professions education. Thus, we investigated the effects of the socio-economic transition on the health professions education system in Mongolia, a transition economy country, and to identify changes in requirements. Methods We used a multi-level perspective to explore the effects of the transition, including the input, process, and output levels of the health professions education system. The input level refers to planning and management, the process level refers to the actual delivery of educational services, and the output level refers to issues related to the health professionals, produced by the system. This study utilized a qualitative research design, including document review and interviews with local representatives. Content analysis and the constant comparative method were used for data analysis. Results We explored tensions in the three levels of the health professions education system. First, medical schools attained academic authority for planning and management without proper regulation and financial support. The government sets tuition fees, which are the only financial resource of medical schools; thus, medical schools attempt to enroll more students in order to adapt to the market environment. Second, the quality of educational services varies across institutions due to the absence of a core curriculum and differences in the learning environment. After the transition, the number of private medical schools rapidly increased without quality control, while hospitals started their own specialized training programs. Third, health professionals are struggling to maintain their professional values and development in the market environment. Fixed salaries lead to a lack of motivation, and quality evaluation measures more likely reflect government control than quality improvement. Conclusions Mongolia continues to face the consequences of the socio-economic transition. Medical schools’ lack of financial authority, the varying quality of educational services, and poor professional development are the major adverse effects. Finding external financial support, developing a core curriculum, and reforming a payment system are recommended.
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Affiliation(s)
- Nomin Amgalan
- Department of Medical Education, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Jwa-Seop Shin
- Department of Medical Education, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Seung-Hee Lee
- Department of Medical Education, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Oyungoo Badamdorj
- Division of Educational Policy and Management, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Oyungerel Ravjir
- Department of Infectious Diseases, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Hyun Bae Yoon
- Office of Medical Education, Seoul National University College of Medicine, Seoul, Korea.
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23
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Al-Qathmi A, Zedan H. The Effect of Incentive Management System on Turnover Rate, Job Satisfaction and Motivation of Medical Laboratory Technologists. Health Serv Res Manag Epidemiol 2021; 8:2333392820988404. [PMID: 33614829 PMCID: PMC7868500 DOI: 10.1177/2333392820988404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/26/2020] [Accepted: 12/26/2020] [Indexed: 12/03/2022] Open
Abstract
Objectives: We investigated factors affecting turnover and assessed satisfaction with an existing Incentive Management System and to which extent it motivates employees. We also provide recommendations to improve the Incentive Management System. Methods: A cross-sectional questionnaire study utilizing a convenience sample from of a population of 250 Medical Laboratory Technologists. Findings: 100 medical laboratory technologists responded to the survey. We found discrepancy in wage allocation to be the most prominent factor affecting turnover intention with 51% strongly agreeing, followed by low incremental system with 48%. Other factors were: limited opportunities for promotion, insufficient allowances and benefits, and lack of continuing education and professional growth opportunities with 49%. 26% of respondents found lack of autonomy/independence to be a factor. Poor workgroup cohesion was least ranked (17%). 39% reported dissatisfaction with workload, 31% were dissatisfied with their provided allowance, with management support, and the working hours, and opportunities for promotion (44%). Opportunities for career growth and higher pay were highest ranked as incentives to remain, and additional vacation time and supportive colleagues to be the least relevant factors. There was a significant correlation between age and motivation levels (r = 0.223, p = 0.026). Discussion and Conclusions: Burnout and turnover can be costly to healthcare organizations, due to the impact on productivity and healthcare quality. Human resource departments must ensure to not only attract skilled employees, but also influence their motivation and retention due to the impact on productivity and health care quality. Incentive management systems support practices to enhance skills, knowledge, abilities and retention rates for healthcare employees. Our study findings support the continued improvement of Incentive Management Systems within the healthcare organization to reduce turnover rates, maximize quality outcomes, and increase the levels of commitment and motivation of employees.
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Affiliation(s)
- Ahlam Al-Qathmi
- Saudi Center for Disease Prevention and Control, Ministry of Health, Riyadh, Saudi Arabia
| | - Haya Zedan
- Department of Public Health, College of Health Sciences, Saudi Electronic University, Riyadh, Saudi Arabia
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24
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Paul E, Bodson O, Ridde V. What theories underpin performance-based financing? A scoping review. J Health Organ Manag 2021; ahead-of-print. [PMID: 33463972 DOI: 10.1108/jhom-04-2020-0161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The study aims to explore the theoretical bases justifying the use of performance-based financing (PBF) in the health sector in low- and middle-income countries (LMICs). DESIGN/METHODOLOGY/APPROACH The authors conducted a scoping review of the literature on PBF so as to identify the theories utilized to underpin it and analyzed its theoretical justifications. FINDINGS Sixty-four studies met the inclusion criteria. Economic theories were predominant, with the principal-agent theory being the most commonly-used theory, explicitly referred to by two-thirds of included studies. Psychological theories were also common, with a wide array of motivation theories. Other disciplines in the form of management or organizational science, political and social science and systems approaches also contributed. However, some of the theories referred to contradicted each other. Many of the studies included only casually alluded to one or more theories, and very few used these theories to justify or support PBF. No theory emerged as a dominant, consistent and credible justification of PBF, perhaps except for the principal-agent theory, which was often inappropriately applied in the included studies, and when it included additional assumptions reflecting the contexts of the health sector in LMICs, might actually warn against adopting PBF. PRACTICAL IMPLICATIONS Overall, this review has not been able to identify a comprehensive, credible, consistent, theoretical justification for using PBF rather than alternative approaches to health system reforms and healthcare providers' motivation in LMICs. ORIGINALITY/VALUE The theoretical justifications of PBF in the health sector in LMICs are under-documented. This review is the first of this kind and should encourage further debate and theoretical exploration of the justifications of PBF.
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Affiliation(s)
- Elisabeth Paul
- School of Public Health, Universite Libre de Bruxelles, Brussels, Belgium
| | | | - Valéry Ridde
- CEPED, Institute for Research on Sustainable Development (IRD), IRD-Université de Paris, Paris, France
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Bezu S, Binyaruka P, Mæstad O, Somville V. Pay-for-performance reduces bypassing of health facilities: Evidence from Tanzania. Soc Sci Med 2020; 268:113551. [PMID: 33309150 DOI: 10.1016/j.socscimed.2020.113551] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/16/2020] [Accepted: 11/21/2020] [Indexed: 11/30/2022]
Abstract
Many patients and expectant mothers in low-income countries bypass local health facilities in search of better-quality services. This study examines the impact of a payment-for-performance (P4P) scheme on bypassing practices among expectant women in Tanzania. We expect the P4P intervention to reduce incidences of bypassing by improving the quality of services in local health facilities, thereby reducing the incentive to migrate. We used a difference-in-difference regression model to assess the impact of P4P on bypassing after one year and after three years. In addition, we implemented a machine learning approach to identify factors that predict bypassing. Overall, 38% of women bypassed their local health service provider to deliver in another facility. Our analysis shows that the P4P scheme significantly reduced bypassing. On average, P4P reduced bypassing in the study area by 17% (8 percentage points) over three years. We also identified two main predictors of bypassing - facility type and the distance to the closest hospital. Women are more likely to bypass if their local facility is a dispensary instead of a hospital or a health center. Women are less likely to bypass if they live close to a hospital.
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Affiliation(s)
- Sosina Bezu
- Chr.Michelsen Institute, P.O.Box 6033, 5892, Bergen, Norway; Diversity Institute, Ryerson University, Canada.
| | - Peter Binyaruka
- Chr.Michelsen Institute, P.O.Box 6033, 5892, Bergen, Norway; Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Ottar Mæstad
- Chr.Michelsen Institute, P.O.Box 6033, 5892, Bergen, Norway
| | - Vincent Somville
- Chr.Michelsen Institute, P.O.Box 6033, 5892, Bergen, Norway; Norwegian School of Economics, 5045, Bergen, Norway
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