1
|
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.
Collapse
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
| |
Collapse
|
2
|
Dasgupta T, De Allegri M, Brenner S, Kaminjolo-Kambala C, Lohmann J. Good while it lasted? Estimating the long-term and withdrawal effects of results-based financing in Malawi on maternal care utilisation using routine data. BMJ Open 2024; 14:e066115. [PMID: 38458806 DOI: 10.1136/bmjopen-2022-066115] [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] [Indexed: 03/10/2024] Open
Abstract
OBJECTIVES This study aimed to evaluate the effect of introduction and subsequent withdrawal of the Results-based Financing for Maternal and Newborn Health Initiative (RBF4MNH) in Malawi on utilisation of facility-based childbirths, antenatal care (ANC) and postnatal care (PNC). DESIGN A controlled interrupted time series design was used with secondary data from the Malawian Health Management Information System. SETTING Healthcare facilities at all levels identified as providing maternity services in four intervention districts and 20 non-intervention districts in Malawi. PARTICIPANTS Routinely collected, secondary data of total monthly service utilisation of facility-based childbirths, ANC and PNC services. INTERVENTIONS The intervention is the RBF4MNH initiative, introduced by the Malawian government in 2013 to improve maternal and infant health outcomes and withdrawn in 2018 after ceasing of donor funding. OUTCOME MEASURES Differences in total volume and trends of utilisation of facility-based childbirths, ANC and PNC services, compared between intervention versus non-intervention districts, for the study period of 90 consecutive months. RESULTS No significant effect was observed, on utilisation trends for any of the three services during the first 2.5 years of intervention. In the following 2.5 years after full implementation, we observed a small positive increase for facility-based childbirths (+0.62 childbirths/month/facility) and decrease for PNC (-0.55 consultations/month/facility) trends of utilisation respectively. After withdrawal, facility-based childbirths and ANC consultations dropped both in immediate volume after removal (-10.84 childbirths/facility and -20.66 consultations/facility, respectively), and in trends of utilisation over time (-0.27 childbirths/month/facility and -1.38 consultations/month/facility, respectively). PNC utilisation levels seemed unaffected in intervention districts against a decline in the rest of the country. CONCLUSIONS Concurrent with wider literature, our results suggest that effects of complex health financing interventions, such as RBF4MNH, can take a long time to be seen. They might not be sustained beyond the implementation period if measures are not adopted to reform existing health financing structures.
Collapse
Affiliation(s)
- Tisha Dasgupta
- Department of Women & Children's Health, King's College London, London, UK
- London School of Hygiene & Tropical Medicine, London, UK
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Stephan Brenner
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Heidelberg, Germany
| | | | - Julia Lohmann
- London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
3
|
Tetui M, Tennant R, Adil M, Bala A, Burns C, Waite N, Grindrod K. "Flying a plane and building it at the same time": Lessons learned from the dynamic implementation of mass vaccination clinics in the Region of Waterloo, Ontario, Canada. Health Res Policy Syst 2023; 21:102. [PMID: 37784061 PMCID: PMC10546698 DOI: 10.1186/s12961-023-01036-z] [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: 12/15/2022] [Accepted: 08/12/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Vaccination plays a critical role during pandemics, and mass vaccination clinics are often an imperative public health measure. These clinics usually consist of multi-disciplinary teams, which can pose significant coordination challenges, yet also present an opportunity for collectively contributing towards mitigating the impact of infection within communities. This study explores the coordination dynamics of the Region of Waterloo's coronavirus disease of 2019 (COVID-19) mass vaccination clinics in Ontario, Canada, between July 2021 and April 2022. METHODS This qualitative study included 16 purposively selected participants working in mass vaccination clinics. Participants were individually interviewed for 40-60 min. An inductive and iterative thematic analysis was undertaken, including open coding, grouping, labelling, regrouping and making sense of the themes. RESULTS Three interrelated themes were created: (1) unpredictable work environment, which was comprised of changing clinic processes and the impact of clinic adjustments to the running of the clinics; (2) clinic cohesion challenges, which included staff role disparities, limited job preparation and clinic system silos; and (3) adaptable and supportive work environment, which was comprised of staff adaptability, dispositional flexibility and a supportive work environment. While the first two themes created a precarious situation in the clinics, the third countered it, leading to a largely successful clinic implementation. CONCLUSIONS The rapid evolution and high transmissibility of COVID-19 in communities required a public health response that felt like flying and building a plane simultaneously - a seemingly impossible yet necessary task. However, an adaptable and supportive work environment was critical for establishing an atmosphere that can overcome challenges from a constantly changing pandemic and the guidance of public health officials. Such lessons gained from understanding the dynamic experiences in mass vaccination clinics are essential for improving the development and operation of future immunization campaigns.
Collapse
Affiliation(s)
- Moses Tetui
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada.
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada.
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
| | - Ryan Tennant
- Systems Design Engineering, Faculty of Engineering, University of Waterloo, Waterloo, Ontario, Canada
| | - Maisha Adil
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Arthi Bala
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Catherine Burns
- Systems Design Engineering, Faculty of Engineering, University of Waterloo, Waterloo, Ontario, Canada
| | - Nancy Waite
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada
| | - Kelly Grindrod
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada
| |
Collapse
|
4
|
Appel I, Lohmann J, De Allegri M, Koulidiati JL, Somda S, Robyn PJ, Badolo H, Brenner S. Improving the readiness and clinical quality of antenatal care - findings from a quasi-experimental evaluation of a performance-based financing scheme in Burkina Faso. BMC Pregnancy Childbirth 2023; 23:352. [PMID: 37189035 DOI: 10.1186/s12884-023-05573-x] [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: 06/19/2022] [Accepted: 04/03/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND While maternal mortality has declined globally, it remains highest in low-income countries. High-quality antenatal care (ANC) can prevent or decrease pregnancy-related complications for mothers and newborns. The implementation of performance-based financing (PBF) schemes in Sub-Saharan Africa to improve primary healthcare provision commonly includes financial indicators linked to ANC service quality indicators. In this study, we examine changes in ANC provision produced by the introduction of a PBF scheme in rural Burkina Faso. METHODS This study followed a quasi-experimental design with two data collection points comparing effects on ANC service quality between primary health facilities across intervention and control districts based on difference-in-differences estimates. Performance scores were defined using data on structural and process quality of care reflecting key clinical aspects of ANC provision related to screening and prevention pertaining to first and follow-up ANC visits. RESULTS We found a statistically significant increase in performance scores by 10 percent-points in facilities' readiness to provide ANC services. The clinical care provided to different ANC client groups scored generally low, especially with respect to preventive care measures, we failed to observe any substantial changes in the clinical provision of ANC care attributable to the PBF. CONCLUSION The observed effect pattern reflects the incentive structure implemented by the scheme, with a stronger focus on structural elements compared with clinical aspects of care. This limited the scheme's overall potential to improve ANC provision at the client level after the observed three-year implementation period. To improve both facility readiness and health worker performance, stronger incentives are needed to increase adherence to clinical standards and patient care outcomes.
Collapse
Affiliation(s)
- Inke Appel
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, University of Heidelberg, INF 130.3, 69120, Heidelberg, Germany.
- Department of Gynecology and Obstetrics, Otto-Von-Guericke University, Magdeburg, Germany.
| | - Julia Lohmann
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, University of Heidelberg, INF 130.3, 69120, Heidelberg, Germany
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, University of Heidelberg, INF 130.3, 69120, Heidelberg, Germany
| | - Jean-Louis Koulidiati
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, University of Heidelberg, INF 130.3, 69120, Heidelberg, Germany
- Institut Supérieur Des Sciences de La Santé, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
| | - Serge Somda
- Centre Muraz, Institut National de Santé Publique (INSP), Bobo-Dioulasso, Burkina Faso
| | - Paul Jacob Robyn
- Health, Nutrition and Population Global Practice, World Bank, D.C., Washington, USA
| | - Hermann Badolo
- Centre Muraz, Institut National de Santé Publique (INSP), Bobo-Dioulasso, Burkina Faso
| | - Stephan Brenner
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, University of Heidelberg, INF 130.3, 69120, Heidelberg, Germany
| |
Collapse
|
5
|
Wang H, Zhao S, Liu Q, Wang J, Yuan B. The Association Between Financial Incentives and Job Performance Among Primary Care Providers in Six Provinces of China. Healthc Policy 2022; 15:2323-2334. [DOI: 10.2147/rmhp.s384114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022] Open
|
6
|
Kachapila M, Kigozi J, Oppong R. Exploring the roles of players in strategic purchasing for healthcare in Africa-a scoping review. Health Policy Plan 2022; 38:97-108. [PMID: 36318330 PMCID: PMC9849715 DOI: 10.1093/heapol/czac093] [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: 07/14/2021] [Revised: 10/25/2022] [Accepted: 10/31/2022] [Indexed: 11/05/2022] Open
Abstract
Following the World Health Organization (WHO) guidance on strategic purchasing in 2000, low- and middle-income countries (LMICs) are trying to shift from passive purchasing (using fixed budgets) to strategic purchasing of healthcare which ties reimbursement to outcomes. However, there is limited evidence on strategic purchasing in Africa. We conducted a scoping literature review aimed at summarizing the roles played by governments, purchasers and providers in relation to citizens/population in strategic purchasing in Africa. The review searched for scientific journal articles that contained data on strategic purchasing collected from Africa. The literature search identified 957 articles of which 80 matched the inclusion criteria and were included in the review. The study revealed that in some countries strategic purchasing has been used as a tool for healthcare reforms or for strengthening systems that were not functional under fixed budgets. However, there was some evidence of a lack of government commitment in taking leading roles and funding strategic purchasing. Further, in some countries the laws need to be revised to accommodate new arrangements that were not part of fixed budgets. The review also established that there were some obstacles within the public health systems that deterred purchasers from promoting efficiency among providers and that prevented providers from having full autonomy in decision making. As African countries strive to shift from passive to strategic purchasing of healthcare, there is need for full government commitment on strategic purchasing. There is need to further revise appropriate legal frameworks to support strategic purchasing, conduct assessments of the healthcare systems before designing strategic purchasing schemes and to sensitize the providers and citizens on their roles and entitlements respectively.
Collapse
Affiliation(s)
- Mwayi Kachapila
- *Corresponding author. Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK. E-mail:
| | - Jesse Kigozi
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Raymond Oppong
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| |
Collapse
|
7
|
Tukay SM, Pasape L, Tani K, Manzi F. Evaluation of the Direct Health Facility Financing Program in Improving Maternal Health Services in Pangani District, Tanzania. Int J Womens Health 2021; 13:1227-1242. [PMID: 34916854 PMCID: PMC8669272 DOI: 10.2147/ijwh.s333900] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/13/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Maternal morbidity and mortality remain significant public health concerns globally, with Tanzania reporting 398 deaths per 100,000 live births annually. While national level data provide some insights into the issue, a focus on sub-national levels is required because of differences in contexts such as rural-urban disparities in maternal mortality. This study examined Direct Health Facility Financing (DHFF) and its effects on the quality of maternal health services in Pangani, a rural district in Tanzania. METHODS This study was conducted in Pangani district of Tanga region in Tanzania. The study used both qualitative and quantitative methods, including 16 in-depth interviews with the council health management teams, facility in charges, maternity nurse in charge, and 5 focus group discussions with community health governing committee members. The number of deliveries that occurred in health facilities, as well as medical supplies, equipment, and reagents purchased by the facilities, were compared using descriptive statistics before and after the DHFF implementation. RESULTS Direct disbursement of funds from the central government through the Ministry of Finance and Planning to the primary health facilities reduced delays in procurement, improved community outreach services, and improved community leaders' engagements. Deliveries occurring at health facilities increased by 33.6% (p < 0.001) one year after the HDFF implementation. Various medicines, delivery kits, and some reagents increased significantly (p < 0.05). However, the lack of computers and poor internet connectivity, an insufficient supply of medical equipment and unstable stock of the Medical Stores Department increased the difficulty of obtaining the missed items from the selected prime vendor. CONCLUSION Overall, this study shows a positive impact of the DHFF on maternal health service delivery in Pangani district. Specifically, an increase in the number of medical supplies, equipment, and reagents necessary to provide maternal health services contributed to the observed increase in facility deliveries by 33.6%. Moreover, the system minimizes unnecessary delays in the procurement processes of required drugs, supplies, and other facility reagents. To maximize the impact of the HDFF system, lack of computers, unstable internet, limited knowledge of the staff about the system, and inadequate health workforce should be addressed. Therefore, strengthening the DHFF system and staff training in-service and on the job is essential for smooth implementation.
Collapse
Affiliation(s)
- Samwel Marco Tukay
- The Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
- Pangani District Council, Tanga, Tanzania
- Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
| | - Liliane Pasape
- The Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
| | - Kassimu Tani
- Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
| | - Fatuma Manzi
- Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
| |
Collapse
|
8
|
Li C, Zhou Y, Zhou C, Lai J, Fu J, Wu Y. Perceptions of nurses and physicians on pay-for-performance in hospital: a systematic review of qualitative studies. J Nurs Manag 2021; 30:521-534. [PMID: 34747079 DOI: 10.1111/jonm.13505] [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: 07/13/2021] [Revised: 10/30/2021] [Accepted: 11/04/2021] [Indexed: 11/29/2022]
Abstract
AIMS To systematically examine perceptions of nurses and physicians on pay-for-performance in hospital. BACKGROUND Pay-for-performance projects have proliferated over the past two decades, most systematic reviews of which solely focused on its effectiveness in primary healthcare and the physicians' or nurses' attitudes. However, systematic reviews of qualitative approaches for better examining perceptions of both nurses and physicians in hospital are lacking. EVALUATION Electronic databases were systematic searched with date from its inception to December 31, 2020. Meta-aggregation synthesis methodology and the conceptual framework of the Theory of Planned Behavior were used to summarize findings. KEY ISSUES A total of nine studies were included. Three major synthesized themes were identified: (1) perceptions of the motivation effects and positive outcomes (2) perceptions about the design defects and negative effects (3) perceptions of the obstacles in the implementation process. CONCLUSION To maximize the intended positive effects, nurses' and physicians' perceptions should be considered and incorporated into the project design and implementation stage. IMPLICATIONS FOR NURSING MANAGEMENT AND RESEARCH The paper gives enlightenment to nurse managers on improving and advancing the cause of nurses when planning for or evaluating their institutions' policies on pay-for-performance in the future research.
Collapse
Affiliation(s)
- Chaixiu Li
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China.,School of Nursing, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Yanni Zhou
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Chunlan Zhou
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Jie Lai
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China.,School of Nursing, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Jiaqi Fu
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China.,School of Nursing, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Yanni Wu
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
| |
Collapse
|
9
|
Darbyshire D, Brewster L, Isba R, Body R, Basit U, Goodwin D. Retention of doctors in emergency medicine: a scoping review of the academic literature. Emerg Med J 2021; 38:663-672. [PMID: 34083428 PMCID: PMC8380914 DOI: 10.1136/emermed-2020-210450] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 01/13/2021] [Indexed: 11/13/2022]
Abstract
Introduction Workforce issues prevail across healthcare; in emergency medicine (EM), previous work improved retention, but the staffing problem changed rather than improved. More experienced doctors provide higher quality and more cost-effective care, and turnover of these physicians is expensive. Research focusing on staff retention is an urgent priority. Methods This study is a scoping review of the academic literature relating to the retention of doctors in EM and describes current evidence about sustainable careers (focusing on factors influencing retention), as well as interventions to improve retention. The established and rigorous JBI scoping review methodology was followed. The data sources searched were MEDLINE, Embase, Cochrane, HMIC and PsycINFO, with papers published up to April 2020 included. Broad eligibility criteria were used to identify papers about retention or related terms, including turnover, sustainability, exodus, intention to quit and attrition, whose population included emergency physicians within the setting of the ED. Papers which solely measured the rate of one of these concepts were excluded. Results Eighteen papers met the inclusion criteria. Multiple factors were identified as linked with retention, including perceptions about teamwork, excessive workloads, working conditions, errors, teaching and education, portfolio careers, physical and emotional strain, stress, burnout, debt, income, work–life balance and antisocial working patterns. Definitions of key terms were used inconsistently. No factors clearly dominated; studies of correlation between factors were common. There were minimal research reporting interventions. Conclusion Many factors have been linked to retention of doctors in EM, but the research lacks an appreciation of the complexity inherent in career decision-making. A broad approach, addressing multiple factors rather than focusing on single factors, may prove more informative.
Collapse
Affiliation(s)
- Daniel Darbyshire
- Health Innovation One, Lancaster University Lancaster Medical School, Lancaster, UK .,Emergency Department, Salford Royal Hospitals NHS Trust, Salford, UK
| | - Liz Brewster
- Health Innovation One, Lancaster University Lancaster Medical School, Lancaster, UK
| | - Rachel Isba
- Health Innovation One, Lancaster University Lancaster Medical School, Lancaster, UK.,Paediatric Emergency Department, North Manchester General Hospital, Manchester, UK
| | - Richard Body
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.,Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK
| | - Usama Basit
- Department of Accident and Emergency, Ipswich Hospital NHS Trust, Colchester, Essex, UK
| | - Dawn Goodwin
- Health Innovation One, Lancaster University Lancaster Medical School, Lancaster, UK
| |
Collapse
|
10
|
Zitti T, Fillol A, Lohmann J, Coulibaly A, Ridde V. Does the gap between health workers' expectations and the realities of implementing a performance-based financing project in Mali create frustration? Glob Health Res Policy 2021; 6:5. [PMID: 33526079 PMCID: PMC7852126 DOI: 10.1186/s41256-021-00189-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 01/25/2021] [Indexed: 11/24/2022] Open
Abstract
Background Performance-Based Financing (PBF), an innovative health financing initiative, was recently implemented in Mali. PBF aims to improve quality of care by motivating health workers. The purpose of this research was to identify and understand how health workers’ expectations related to their experiences of the first cycle of payment of PBF subsidies, and how this experience affected their motivation and sentiments towards the intervention. We pose the research question, “how does the process of PBF subsidies impact the motivation of health workers in Mali?” Methods We adopted a qualitative approach using multiple case studies. We chose three district hospitals (DH 1, 2 and 3) in three health districts (district 1, 2 and 3) among the ten in the Koulikoro region. Our cases correspond to the three DHs. We followed the principle of data source triangulation; we used 53 semi-directive interviews conducted with health workers (to follow the principle of saturuation), field notes, and documents relating to the distribution grids of subsidies for each DH. We analyzed data in a mixed deductive and inductive manner. Results The results show that the PBF subsidies led to health workers feeling more motivated to perform their tasks overall. Beyond financial motivation, this was primarily due to PBF allowing them to work more efficiently. However, respondents perceived a discrepancy between the efforts made and the subsidies received. The fact that their expectations were not met led to a sense of frustration and disappointment. Similarly, the way in which the subsidies were distributed and the lack of transparency in the distribution process led to feelings of unfairness among the vast majority of respondents. The results show that frustrations can build up in the early days of the intervention. Conclusion The PBF implementation in Mali left health workers frustrated. The short overall implementation period did not allow actors to adjust their initial expectations and motivational responses, neither positive nor negative. This underlines how short-term interventions might not just lack impact, but instil negative sentiments likely to carry on into the future.
Collapse
Affiliation(s)
- Tony Zitti
- Centre Population et Développement (Ceped), Institut de recherche pour le développement (IRD) et Université de Paris, Inserm ERL 1244, 45 rue des Saints-Pères, 75006, Paris, France. .,École doctorale Pierre Louis de santé publique, Université de Paris, Paris, France. .,ONG Miseli, Bamako, Mali.
| | - Amandine Fillol
- Centre Population et Développement (Ceped), Institut de recherche pour le développement (IRD) et Université de Paris, Inserm ERL 1244, 45 rue des Saints-Pères, 75006, Paris, France.,Ecole de santé publique de l'Université de Montréal, Montréal, Canada
| | - Julia Lohmann
- London School of Hygiene & Tropical Medicine, London, UK.,Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Abdourahmane Coulibaly
- ONG Miseli, Bamako, Mali.,Faculté de Médicine et d'Odontostomatologie, Université des Sciences, des Techniques et des Technologies, Bamako, Mali
| | - Valéry Ridde
- Centre Population et Développement (Ceped), Institut de recherche pour le développement (IRD) et Université de Paris, Inserm ERL 1244, 45 rue des Saints-Pères, 75006, Paris, France
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
A realist review to assess for whom, under what conditions and how pay for performance programmes work in low- and middle-income countries. Soc Sci Med 2020; 270:113624. [PMID: 33373774 DOI: 10.1016/j.socscimed.2020.113624] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/08/2020] [Accepted: 12/14/2020] [Indexed: 12/12/2022]
Abstract
Pay for performance (P4P) programmes are popular health system-focused interventions aiming to improve health outcomes in low-and middle-income countries (LMICs). This realist review aims to understand how, why and under what circumstance P4P works in LMICs.We systematically searched peer-reviewed and grey literature databases, and examined the mechanisms underpinning P4P effects on: utilisation of services, patient satisfaction, provider productivity and broader health system, and contextual factors moderating these. This evidence was then used to construct a causal loop diagram.We included 112 records (19 grey literature; 93 peer-reviewed articles) assessing P4P schemes in 36 countries. Although we found mixed evidence of P4P's effects on identified outcomes, common pathways to improved outcomes include: community outreach; adherence to clinical guidelines, patient-provider interactions, patient trust, facility improvements, access to drugs and equipment, facility autonomy, and lower user fees. Contextual factors shaping the system response to P4P include: degree of facility autonomy, efficiency of banking, role of user charges in financing public services; staffing levels; staff training and motivation, quality of facility infrastructure and community social norms. Programme design features supporting or impeding health system effects of P4P included: scope of incentivised indicators, fairness and reach of incentives, timely payments and a supportive, robust verification system that does not overburden staff. Facility bonuses are a key element of P4P, but rely on provider autonomy for maximum effect. If health system inputs are vastly underperforming pre-P4P, they are unlikely to improve only due to P4P. This is the first realist review describing how and why P4P initiatives work (or fail) in different LMIC contexts by exploring the underlying mechanisms and contextual and programme design moderators. Future studies should systematically examine health system pathways to outcomes for P4P and other health system strengthening initiatives, and offer more understanding of how programme design shapes mechanisms and effects.
Collapse
|
13
|
Martin B, Jones J, Miller M, Johnson-Koenke R. Health Care Professionals' Perceptions of Pay-for-Performance in Practice: A Qualitative Metasynthesis. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2020; 57:46958020917491. [PMID: 32448014 PMCID: PMC7249558 DOI: 10.1177/0046958020917491] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Incentive-based pay-for-performance (P4P) models have been introduced during the
last 2 decades as a mechanism to improve the delivery of evidence-based care
that ensures clinical quality and improves health outcomes. There is mixed
evidence that P4P has a positive effect on health outcomes and researchers cite
lack of engagement from health care professionals as a limiting factor. This
qualitative metasynthesis of existing qualitative research was conducted to
integrate health care professionals’ perceptions of P4P in clinical practice.
Four themes emerged during the research process: positive perceptions of the
value of performance measurement and associated financial incentives; negative
perceptions of the performance measurement and associated financial incentives;
perceptions of how P4P programs influence the quality/appropriateness of care;
and perceptions of the influence of P4P program on professional roles and
workplace dynamics. Identifying factors that influence health care
professionals’ perceptions about this type of value-based payment model will
guide future research.
Collapse
Affiliation(s)
| | | | - Matthew Miller
- University of Colorado, Aurora, USA.,VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, USA
| | - Rachel Johnson-Koenke
- University of Colorado, Aurora, USA.,Rocky Mountain Regional VA Medical Center, Denver, CO, USA
| |
Collapse
|
14
|
Coulibaly A, Gautier L, Zitti T, Ridde V. Implementing performance-based financing in peripheral health centres in Mali: what can we learn from it? Health Res Policy Syst 2020; 18:54. [PMID: 32493360 PMCID: PMC7268714 DOI: 10.1186/s12961-020-00566-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 05/01/2020] [Indexed: 12/04/2022] Open
Abstract
Introduction Numerous sub-Saharan African countries have experimented with performance-based financing (PBF) with the goal of improving health system performance. To date, few articles have examined the implementation of this type of complex intervention in Francophone West Africa. This qualitative research aims to understand the process of implementing a PBF pilot project in Mali's Koulikoro region. Method We conducted a contrasted multiple case study of performance in 12 community health centres in three districts. We collected 161 semi-structured interviews, 69 informal interviews and 96 non-participant observation sessions. Data collection and analysis were guided by the Consolidated Framework for Implementation Research adapted to the research topic and local context. Results Our analysis revealed that the internal context of the PBF implementation played a key role in the process. High-performing centres exercised leadership and commitment more strongly than low-performing ones. These two characteristics were associated with taking initiatives to promote PBF implementation and strengthening team spirit. Information regarding the intervention was best appropriated by qualified health professionals. However, the limited duration of the implementation did not allow for the emergence of networks or champions. The enthusiasm initially generated by PBF quickly dissipated, mainly due to delays in the implementation schedule and the payment modalities. Conclusion PBF is a complex intervention in which many actors intervene in diverse contexts. The initial level of performance and the internal and external contexts of primary healthcare facilities influence the implementation of PBF. Future work in this area would benefit from an interdisciplinary approach combining public health and anthropology to better understand such an intervention. The deductive–inductive approach must be the stepping-stone of such a methodological approach.
Collapse
Affiliation(s)
- Abdourahmane Coulibaly
- Miseli Research NGO, Bamako, Mali. .,Faculty of Medicine and Odonto-Stomatology, Université des Sciences, des Techniques et des Technologies, Bamako, Mali. .,UMI 3189 Environnement, Santé, Sociétés (CNRS, UCAD, UGB, USTTB, CNRST), Dakar, Sénégal.
| | - Lara Gautier
- Department of Sociology, McGill University, Montreal, Canada.,Department of Social and Preventive Medicine, University of Montreal, Montreal, Canada
| | - Tony Zitti
- Miseli Research NGO, Bamako, Mali.,CEPED, Institute for Research on Sustainable Development, IRD-Université de Paris, ERL INSERM SAGESUD, Paris, France.,École doctorale Pierre Louis de santé publique: épidémiologie et sciences de l'information biomédicale, Université de Paris, Paris, France
| | - Valéry Ridde
- CEPED, Institute for Research on Sustainable Development, IRD-Université de Paris, ERL INSERM SAGESUD, Paris, France
| |
Collapse
|
15
|
Kovacs RJ, Powell-Jackson T, Kristensen SR, Singh N, Borghi J. How are pay-for-performance schemes in healthcare designed in low- and middle-income countries? Typology and systematic literature review. BMC Health Serv Res 2020; 20:291. [PMID: 32264888 PMCID: PMC7137308 DOI: 10.1186/s12913-020-05075-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pay for performance (P4P) schemes provide financial incentives to health workers or facilities based on the achievement of pre-specified performance targets and have been widely implemented in health systems across low and middle-income countries (LMICs). The growing evidence base on P4P highlights that (i) there is substantial variation in the effect of P4P schemes on outcomes and (ii) there appears to be heterogeneity in incentive design. Even though scheme design is likely a key determinant of scheme effectiveness, we currently lack systematic evidence on how P4P schemes are designed in LMICs. METHODS We develop a typology to classify the design of P4P schemes in LMICs, which highlights different design features that are a priori likely to affect the behaviour of incentivised actors. We then use results from a systematic literature review to classify and describe the design of P4P schemes that have been evaluated in LMICs. To capture academic publications, Medline, Embase, and EconLit databases were searched. To include relevant grey literature, Google Scholar, Emerald Insight, and websites of the World Bank, WHO, Cordaid, Norad, DfID, USAID and PEPFAR were searched. RESULTS We identify 41 different P4P schemes implemented in 29 LMICs. We find that there is substantial heterogeneity in the design of P4P schemes in LMICs and pinpoint precisely how scheme design varies across settings. Our results also highlight that incentive design is not adequately being reported on in the literature - with many studies failing to report key design features. CONCLUSIONS We encourage authors to make a greater effort to report information on P4P scheme design in the future and suggest using the typology laid out in this paper as a starting point.
Collapse
Affiliation(s)
- Roxanne J Kovacs
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, London, UK.
| | - Timothy Powell-Jackson
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, London, UK
| | - Søren R Kristensen
- Imperial College London, Faculty of Medicine, Institute of Global Health Innovation, London, UK
| | - Neha Singh
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, London, UK
| | - Josephine Borghi
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, London, UK
| |
Collapse
|
16
|
Petross C, McMahon S, Lohmann J, Chase RP, Muula AS, De Allegri M. Intended and unintended effects: community perspectives on a performance-based financing programme in Malawi. BMJ Glob Health 2020; 5:e001894. [PMID: 32337084 PMCID: PMC7170427 DOI: 10.1136/bmjgh-2019-001894] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 01/20/2020] [Accepted: 01/27/2020] [Indexed: 11/04/2022] Open
Abstract
Background Several performance-based financing (PBF) evaluations have been undertaken in low-income countries, yet few have examined community perspectives of care amid PBF programme implementation. We assessed community members' perspectives of Support for Service Delivery Integration - Performance-Based Incentives ('SSDI-PBI'), a PBF intervention in Malawi, and explored some of the unintended effects that emerged amid implementation. Methods We conducted 30 focus group discussions: 17 with community leaders and 13 with mothers within catchment areas of SSDI-PBI implementing facilities. We analysed data using the framework approach. Results Community leaders and women had mixed impressions regarding the effect of SSDI-PBI on service delivery in facilities. They highlighted several improvements (including improved dialogue between staff and community, and cleaner, better-equipped facilities with enhanced privacy), but also persisting challenges (including inadequate and overworked staff, overcrowded facilities and long distances to facilities) related to services in SSDI-PBI-implementing facilities. Further, respondents described how four targeted service indicators related to maternal risk factor management, antenatal care (ANC) in the first trimester, skilled birth attendance and couple's HIV testing sparked unintended negative effects as experienced by women and communities. The unintended effects included women returning home for delivery, women feeling uncertain about their pregnancy status, women feeling betrayed or frustrated by the quality of care provided and partnerless women being denied ANC. Conclusion PBF programmes such as SSDI-PBI may improve some aspects of service delivery. However, to achieve system improvement, not only should necessary tools (such as medicines, equipment and human resources) be in place, but also programme priorities must be congruent with cultural expectations. Finally, facilities must be better supported to expect and then address increases in client load and heightened expectations in relation to services.
Collapse
Affiliation(s)
- Chisomo Petross
- University of Malawi, Kamuzu College of Nursing, Private Bag 1, Lilongwe, Malawi
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Shannon McMahon
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Julia Lohmann
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, Keppel Street, London WC1E 7HT, UK
| | - Rachel P Chase
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Adamson S. Muula
- Department of Public health, University of Malawi, College of Medicine, Blantyre 3, Malawi
- Africa Center of Excellence in Public Health, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| |
Collapse
|
17
|
Towards improved health service quality in Tanzania: contribution of a supportive supervision approach to increased quality of primary healthcare. BMC Health Serv Res 2019; 19:848. [PMID: 31747932 PMCID: PMC6865029 DOI: 10.1186/s12913-019-4648-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 10/16/2019] [Indexed: 11/26/2022] Open
Abstract
Background Universal Health Coverage only leads to the desired health outcomes if quality of health services is ensured. In Tanzania, quality has been a major concern for many years, including the problem of ineffective and inadequate routine supportive supervision of healthcare providers by council health management teams. To address this, we developed and assessed an approach to improve quality of primary healthcare through enhanced routine supportive supervision. Methods Mixed methods were used, combining trends of quantitative quality of care measurements with qualitative data mainly collected through in-depth interviews. The former allowed for identification of drivers of quality improvements and the latter investigated the perceived contribution of the new supportive supervision approach to these improvements. Results The results showed that the new approach managed to address quality issues that could be solved either solely by the healthcare provider, or in collaboration with the council. The new approach was able to improve and maintain crucial primary healthcare quality standards across different health facility level and owner categories in various contexts. Conclusion Together with other findings reported in companion papers, we could show that the new supportive supervision approach not only served to assess quality of primary healthcare, but also to improve and maintain crucial primary healthcare quality standards. The new approach therefore presents a powerful tool to support, guide and drive quality improvement measures within council. It can thus be considered a suitable option to make routine supportive supervision more effective and adequate.
Collapse
|
18
|
Chimhutu V, Tjomsland M, Mrisho M. Experiences of care in the context of payment for performance (P4P) in Tanzania. Global Health 2019; 15:59. [PMID: 31619291 PMCID: PMC6796428 DOI: 10.1186/s12992-019-0503-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 09/26/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tanzania is one of many low income countries committed to universal health coverage and Sustainable Development Goals. Despite these bold goals, there is growing concern that the country could be off-track in meeting these goals. This prompted the Government of Tanzania to look for ways to improve health outcomes in these goals and this led to the introduction of Payment for Performance (P4P) in the health sector. Since the inception of P4P in Tanzania a number of impact, cost-effective and process evaluations have been published with less attention being paid to the experiences of care in this context of P4P, which we argue is important for policy agenda setting. This study therefore explores these experiences from the perspectives of health workers, service users and community health governing committee members. METHODS A qualitative study design was used to elicit experiences of health workers, health service users and health governing committee members in Rufiji district of the Pwani region in Tanzania. The Payment for Performance pilot was introduced in Pwani region in 2011 and data presented in this article is based on this pilot. A total of 31 in-depth interviews with health workers and 9 focus group discussions with health service users and health governing committee members were conducted. Collected data was analysed through qualitative content analysis. RESULTS Study informants reported positive experiences with Payment for Performance and highlighted its potential in improving the availability, accessibility, acceptability and quality of care (AAAQ). However, the study found that persistent barriers for achieving AAAQ still exist in the health system of Tanzania and these contribute to negative experiences of care in the context of P4P. CONCLUSION Our findings suggest that there are a number of positive aspects of care that can be improved by Payment for Performance. However its targeted nature on specific services means that these improvements cannot be generalized at health facility level. Additionally, health workers can go as far as they can in improving health services but some factors that act as barriers as demonstrated in this study are out of their control even in the context of Payment for Performance. In this regard there is need to exercise caution when implementing such initiatives, despite seemingly positive targeted outcomes.
Collapse
Affiliation(s)
- Victor Chimhutu
- Department of Health Promotion and Development, University of Bergen, P.O Box 7807, 5020 Bergen, Norway
| | - Marit Tjomsland
- Department of Social Science, Faculty of Education, Western Norway University of Applied Sciences, P.O Box 7030, 5020 Bergen, Norway
| | - Mwifadhi Mrisho
- Ifakara Health Institute, P.O Box 78373, Dar es Salaam, Tanzania
| |
Collapse
|
19
|
Should performance-based incentives be used to motivate health care providers? Views of health sector managers in Cambodia, China and Pakistan. HEALTH ECONOMICS POLICY AND LAW 2019; 15:247-260. [PMID: 30700342 DOI: 10.1017/s1744133118000506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This study qualitatively investigates what factors apart from or in addition to financial incentives can encourage better performance of frontline health care providers. We interviewed health sector managers in Pakistan, Cambodia and China, and they highlighted many potential limitations in the applicability of financial incentives in their contexts. There was a consistent view that providers are not always primarily driven by monetary rewards and that non-monetary rewards - such as recognition from direct supervisors and career development - could have a greater influence on performance. Managers also highlighted several challenges related to the design and implementation of performance management schemes: supervisors may not have performance information necessary to determine which agents to reward; when performance information is available, organisational culture may value other attributes such as social ties or years of experience; finally, concentration of power at higher levels of the health system can reduce supervisors' ability to manage performance, rewards and accountability. Although health sector managers were enthusiastic about measures to improve performance of providers, our study indicated that specific social, cultural and health system factors may mean that non-monetary rewards and structural changes to support a more transparent and meritocratic working environment should also be considered.
Collapse
|
20
|
Borghi J, Singh NS, Brown G, Anselmi L, Kristensen S. Understanding for whom, why and in what circumstances payment for performance works in low and middle income countries: protocol for a realist review. BMJ Glob Health 2018; 3:e000695. [PMID: 29988988 PMCID: PMC6035508 DOI: 10.1136/bmjgh-2017-000695] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 05/03/2018] [Accepted: 05/17/2018] [Indexed: 12/22/2022] Open
Abstract
Background Many low and middle income countries (LMIC) are implementing payment for performance (P4P) schemes to strengthen health systems and make progress towards universal health coverage. A number of systematic reviews have considered P4P effectiveness but did not explore how P4P works in different settings to improve outcomes or shed light on pathways or mechanisms of programme effect. This research will undertake a realist review to investigate how, why and in what circumstances P4P leads to intended and unintended outcomes in LMIC. Methods Our search was guided by an initial programme theory of mechanisms and involved a systematic search of Medline, Embase, Popline, Business Source Premier, Emerald Insight and EconLit databases for studies on P4P and health in LMIC. Inclusion and exclusion criteria identify literature that is relevant to the initial programme theory and the research questions underpinning the review. Retained evidence will be used to test, revise or refine the programme theory and identify knowledge gaps. The evidence will be interrogated by examining the relationship between context, mechanisms and intended and unintended outcomes to establish what works for who, in which contexts and why. Discussion By synthesising current knowledge on how P4P affects health systems to produce outcomes in different contexts and to what extent the programme design affects this, we will inform more effective P4P programmes to strengthen health systems and achieve sustainable service delivery and health impacts.
Collapse
Affiliation(s)
- Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Neha S Singh
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Garrett Brown
- School of Politics and International Studies, University of Leeds, Leeds, UK
| | - Laura Anselmi
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - Soren Kristensen
- Faculty of Medicine, Institute of Global Health Innovation, Centre for Health Policy, Imperial College, London, UK
| |
Collapse
|
21
|
Lohmann J, Muula AS, Houlfort N, De Allegri M. How does performance-based financing affect health workers' intrinsic motivation? A Self-Determination Theory-based mixed-methods study in Malawi. Soc Sci Med 2018; 208:1-8. [PMID: 29751178 DOI: 10.1016/j.socscimed.2018.04.053] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 04/25/2018] [Accepted: 04/27/2018] [Indexed: 11/26/2022]
Abstract
"Intrinsic motivation crowding out", the erosion of high-quality, sustainable motivation through the introduction of financial incentives, is one of the most frequently discussed but yet little researched potential unfavorable consequence of Performance-based Financing (PBF). We used the opportunity of the introduction of PBF in Malawi to investigate whether and how PBF affected intrinsic motivation, using a mixed-methods research design theoretically grounded in Self-Determination Theory (SDT). The quantitative component served to estimate the impact of PBF on intrinsic motivation, relying on a controlled pre- and post-test design, with data collected from health workers in 23 intervention and 10 comparison facilities before (March/April 2013; n = 70) and approximately two years after (June/July 2015; n = 71) the start of the intervention. The qualitative component, relying on in-depth interviews with health workers in selected intervention facilities one (April 2014; n = 21) and two (September 2015; n = 20) years after the start of PBF, served to understand how PBF did or did not bring about change in intrinsic motivation. Specifically, it allowed us to examine how the various motivation-relevant elements and consequences of PBF impacted health workers' basic psychological needs for autonomy, competence, and relatedness, which SDT postulates as central to intrinsic motivation. Our results suggest that PBF did not affect health workers' overall intrinsic motivation levels, with the intervention having had both positive and negative effects on psychological needs satisfaction. To maximize positive PBF effects on intrinsic motivation, our results underline the potential value of explicit strategies to mitigate unintended negative impact of unavoidable design, implementation, and contextual challenges, for instance by building autonomy support activities into PBF designs.
Collapse
Affiliation(s)
- Julia Lohmann
- Institute of Public Health, Medical Faculty, Heidelberg University, Germany.
| | - Adamson S Muula
- Department of Public Health, College of Medicine, University of Malawi, Malawi
| | | | - Manuela De Allegri
- Institute of Public Health, Medical Faculty, Heidelberg University, Germany
| |
Collapse
|
22
|
Context matters (but how and why?) A hypothesis-led literature review of performance based financing in fragile and conflict-affected health systems. PLoS One 2018; 13:e0195301. [PMID: 29614115 PMCID: PMC5882151 DOI: 10.1371/journal.pone.0195301] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 03/20/2018] [Indexed: 12/31/2022] Open
Abstract
Performance-based financing (PBF) schemes have been expanding rapidly across low and middle income countries in the past decade, with considerable external financing from multilateral, bilateral and global health initiatives. Many of these countries have been fragile and conflict-affected (FCAS), but while the influence of context is acknowledged to be important to the operation of PBF, there has been little examination of how it affects adoption and implementation of PBF. This article lays out initial hypotheses about how FCAS contexts may influence the adoption, adaption, implementation and health system effects of PBF. These are then interrogated through a review of available grey and published literature (140 documents in total, covering 23 PBF schemes). We find that PBF has been more common in FCAS contexts, which were also more commonly early adopters. Very little explanation of the rationale for its adoption, in particular in relation with the contextual features, is given in programme documents. However, there are a number of factors which could explain this, including the greater role of external actors and donors, a greater openness to institutional reform, and lower levels of trust within the public system and between government and donors, all of which favour more contractual approaches. These suggest that rather than emerging despite fragility, conditions of fragility may favour the rapid emergence of PBF. We also document few emerging adaptations of PBF to humanitarian settings and limited evidence of health system effects which may be contextually driven, but these require more in-depth analysis. Another area meriting more study is the political economy of PBF and its diffusion across contexts.
Collapse
|
23
|
Paul E, Albert L, Bisala BN, Bodson O, Bonnet E, Bossyns P, Colombo S, De Brouwere V, Dumont A, Eclou DS, Gyselinck K, Hane F, Marchal B, Meloni R, Noirhomme M, Noterman JP, Ooms G, Samb OM, Ssengooba F, Touré L, Turcotte-Tremblay AM, Van Belle S, Vinard P, Ridde V. Performance-based financing in low-income and middle-income countries: isn't it time for a rethink? BMJ Glob Health 2018; 3:e000664. [PMID: 29564163 PMCID: PMC5859812 DOI: 10.1136/bmjgh-2017-000664] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 01/01/2023] Open
Abstract
This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches.
Collapse
Affiliation(s)
- Elisabeth Paul
- Tax Institute, Université de Liège, Liège, Belgium
- Faculty of Social Sciences, Université de Liège, Liège, Belgium
| | - Lucien Albert
- International Health Unit, University of Montreal, Montreal, Quebec, Canada
| | - Badibanga N'Sambuka Bisala
- Expert in district health systems based on primary healthcare, Groupe d'Appui à la Recherche et Enseignement en Santé Publique, Mbuji-Mayi, Democratic Republic of the Congo
| | - Oriane Bodson
- Faculty of Social Sciences, Université de Liège, Liège, Belgium
| | - Emmanuel Bonnet
- Résiliences, Research Institute for Development (IRD), Bondy, France
| | - Paul Bossyns
- Health Sector Thematic Unit, Belgian Development Agency (ENABEL), Brussels, Belgium
| | | | - Vincent De Brouwere
- Department of Public Health, Institute of Tropical Medicine Antwerp, Antwerpen, Belgium
| | - Alexandre Dumont
- CEPED, Research Institute for Development (IRD), Paris Descartes University, INSERM, Paris, France
| | | | - Karel Gyselinck
- Health Sector Thematic Unit, Belgian Development Agency (ENABEL), Brussels, Belgium
| | - Fatoumata Hane
- Department of Sociology, Université Assane Seck, Ziguinchor, Senegal
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine Antwerp, Antwerpen, Belgium
| | | | | | | | - Gorik Ooms
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Oumar Mallé Samb
- Global Health, Department of Health Sciences, Université du Québec en Abitibi-Témiscamingue, Quebec City, Quebec, Canada
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Laurence Touré
- Anthropologist, Research Association Miseli, Bamako, Mali
| | | | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine Antwerp, Antwerpen, Belgium
| | | | - Valéry Ridde
- CEPED, Research Institute for Development (IRD), Paris Descartes University, INSERM, Paris, France
| |
Collapse
|
24
|
Ridde V, Yaogo M, Zongo S, Somé P, Turcotte‐Tremblay A. Twelve months of implementation of health care performance-based financing in Burkina Faso: A qualitative multiple case study. Int J Health Plann Manage 2018; 33:e153-e167. [PMID: 28671285 PMCID: PMC5900741 DOI: 10.1002/hpm.2439] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 05/25/2017] [Indexed: 11/18/2022] Open
Abstract
To improve health services' quantity and quality, African countries are increasingly engaging in performance-based financing (PBF) interventions. Studies to understand their implementation in francophone West Africa are rare. This study analysed PBF implementation in Burkina Faso 12 months post-launch in late 2014. The design was a multiple and contrasted case study involving 18 cases (health centres). Empirical data were collected from observations, informal (n = 224) and formal (n = 459) interviews, and documents. Outside the circle of persons trained in PBF, few in the community had knowledge of it. In some health centres, the fact that staff were receiving bonuses was intentionally not announced to populations and community leaders. Most local actors thought PBF was just another project, but the majority appreciated it. There were significant delays in setting up agencies for performance monitoring, auditing, and contracting, as well as in the payment. The first audits led rapidly to coping strategies among health workers and occasionally to some staging beforehand. No community-based audits had yet been done. Distribution of bonuses varied from one centre to another. This study shows the importance of understanding the implementation of public health interventions in Africa and of uncovering coping strategies.
Collapse
Affiliation(s)
- Valéry Ridde
- University of Montreal Public Health Research Institute (IRSPUM)MontrealQCCanada
- University of Montreal School of Public Health (ESPUM)MontrealQCCanada
| | - Maurice Yaogo
- Université Catholique de l'Afrique de l'Ouest—Unité Universitaire à Bobo‐DioulassoBobo‐DioulassoBurkina Faso
- Association Zama Forum pour la Diffusion des Connaissances et des Expériences novatrices en Afrique (Zama Forum/ADCE—Afrique)Bobo‐DioulassoBurkina Faso
| | - Sylvie Zongo
- Institut des Sciences des Sociétés (INSS‐CNRST)OuagadougouBurkina Faso
| | - Paul‐André Somé
- Association Action Gouvernance Intégration Renforcement (AGIR)OuagadougouBurkina Faso
| | - Anne‐Marie Turcotte‐Tremblay
- University of Montreal Public Health Research Institute (IRSPUM)MontrealQCCanada
- University of Montreal School of Public Health (ESPUM)MontrealQCCanada
| |
Collapse
|
25
|
Lohmann J, Wilhelm D, Kambala C, Brenner S, Muula AS, De Allegri M. ‘The money can be a motivator, to me a little, but mostly PBF just helps me to do better in my job.’ An exploration of the motivational mechanisms of performance-based financing for health workers in Malawi. Health Policy Plan 2017; 33:183-191. [DOI: 10.1093/heapol/czx156] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2017] [Indexed: 12/22/2022] Open
|