April 7, 2011
Alex Ergo, PhDBroad Branch Associates
Using Performance-Based Incentives to Enhance the Quality of MNCH Interventions in Developing Countries
The Maternal and Child Health Integrated Program (MCHIP)
USAID Bureau for Global Health’s flagship maternal, newborn and child health program
Working in well over 30 countries worldwide
MCHIP supports programming and opportunities for integration in: Maternal, Newborn and Child Health Immunization, Family Planning, Malaria,
HIV/AIDS Water & Sanitation, Urban Health, Health
Systems Strengthening
3
Outline
Performance-based incentives (PBI): concept
PBI in developing countries: quick overview
Incentivizing quality of care: how?
What can we learn from high-income countries?
Performance-Based Incentives (PBI):An Umbrella Term
“Any program that rewards the delivery of one or more outputs or outcomes by one or more incentives, financial or otherwise, upon verification that the agreed-upon result has actually been delivered.”
Musgrove, Rewards for Good Performance or Results:A Short Glossary
4
5
“Business as usual” is not enough
PBI: A Paradigm Shift in Global Health
Paying for andtracking inputs
Verifying and paying for results
6
PBI is more than a financing mechanism
It is a powerful tool to strengthen health systems
PBI: A Paradigm Shift in Global Health
7
Performance-Based AidPayments to national governments conditional on increasing health outputs or achieving impact
Supply-Side IncentivesPayments to sub-national levels of government, facilities, teams of health workers, or individual providers, conditional on increasing health outputs or outcomes
Demand-Side IncentivesPayments to communities, households or individuals, conditional on engaging in pre-agreed healthy behaviors
PBI Can Take Many Forms
8
Payments to sub-national levels of government
e.g. Argentina, Benin, Burundi, Rwanda, Senegal, Tanzania, Zambia
Payments to facilities, or teams of health workers
e.g. Belize, Benin, Burundi, Egypt, Honduras, Rwanda, Senegal, Tanzania, Zambia
Payments to service delivery NGOse.g. Afghanistan, DRC, Haiti, Liberia, South Sudan
On the Supply Side
9
Payments to individuals or households conditional on pre-agreed healthy behaviors
e.g. Brazil, Colombia, Mexico, Nicaragua, Tanzania Vouchers given or sold to individuals
redeemable for particular servicese.g. Bangladesh, Kenya, Nepal, Pakistan, Uganda
Incentives to TB patients for adhering to treatment regimen
e.g. Russia, US
On the Demand Side
Potential Health Impact
Large scope for increasing utilization AND improving quality in many areas
Immunization Nutrition Effective antenatal care Safe deliveries Family planning Malaria prevention and treatment TB detection and treatment HIV prevention and treatment
…But Many Implementation Challenges
Weak health information systems Dysfunctional supply chains Poor management capacity at all levels Truly independent external verifiers rare and
costly Shortage of well-trained human resources Sustainability – Concerns about how to pay for
implementation and financial incentives
PBI itself may help address some of these challenges
Quality of Care - Definition
“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”
US Institute of Medicine
13
14
Incentivizing Quality of Care: How?
Different countries/schemes take different approaches: Incentives linked to the achievement of
accreditation Incentives linked to improvements in scores on
quality assessment tools
Incentives linked to adherence to treatment (demand) or treatment protocols (supply)
Incentives linked to ‘quantity’ indicators reflecting a certain level of quality
Quality of Care as a carrot or as a stick
15
Can We Learn From High-Income Countries?
The environments differ in some aspects: Low- and middle-income countries: under-
utilization of even the most basic services High-income countries: over-utilization of
highly specialized services
But they are surprisingly similar in other aspects:
Wide variations in how providers treat a same diagnosis: poor adherence to standard treatment guidelines
Under-utilization of preventive services
16
What all countries have in common:
Increased emphasis on incentivizing quality of care
Can We Learn From High-Income Countries?
17
Incentivizing quality of care in high-income countries – tendency: Incentives linked to maintaining population
healthywhile avoiding preventable hospitalization andemergency servicese.g. Accountable Care Organizations in the US
Incentives linked to reductions in unnecessary hospital admissions e.g. by refusing to pay for hospital re-admissions
What Can We Learn From High-Income Countries?
18
Incentivizing quality of care is a dynamic process that needs continuous reengineering
Smart use of information technology might be a powerful driver
Incentives should promote a better coordination between the different levels of care / types of providers
Importance of being able to demonstrate what works, how and when
What Can We Learn From High-Income Countries?
For More Information…
www.RBFhealth.org
www.HealthSystems2020.org
http://www.cgdev.org/section/initiatives/_active/ghprn/workinggroups/performance
19
Thank you!
wwww.mchip.net
Follow us on:
21