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Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane University’s School of Public Health Training Resources Group
Catalyzing Maternal and Child Health Results by Paying for Performance: Evidence from Developing Countries
Catherine Connor and Rena Eichler
Health Systems 20/20 Project15 November 2010Health Systems Research Symposium
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What does pay for performance have to do with reaching universal coverage?
Feasibility of Insurance Design and Implementation
Monitoring and Evaluation
Financing
options
Benefits
package
Pop Covera
ge
Opera-tions
Organiza-
tional structur
e
Provider
engage-ment
Incentives to use priority
services
Pay providers for quality or
efficiency
Incentives to cover hard-to-reach populations
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Presentation Objectives
What is Pay for Performance?
Highlights from on-line survey of country experiences
Expanding access for maternal and child health results: the case of Burundi
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What we mean by P4P
Funds, Goods, Other
PayerDonars. Govenment, NGOs Health Programs, Insurers
RecipientPatients or Families
Service Providers (facility or health worker) NGO or program implementerGovernment - Local or National
Results
Demand Side
Supply Side
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What is P4P?
Many terms: results-based financing, performance-based financing, performance-based contracting, conditional cash transfers, …
One common definition: “Transfer of money or material goods conditional
on taking a measurable health related action or achieving a predetermined performance target” *
*From the Center for Global Development Working Group on Performance-Based Incentives
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Pay-for-Performance (P4P)An explosion of interest and funding
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Flat salaries for providers leads to low incentives to provide quantity or quality or to serve the poor
Fixing incentives is important complement to infrastructure, technical, and capacity building interventions
P4P can be combined with any provider payment method: Salary, FFS, capitation, case-based, global budget
Why is P4P getting so much attention?
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Snapshot of P4P Country Survey
Why do this survey? To fill the gap between growing
experimentation and little documentation
Global online survey 2009 90 e-responses 25 responses summarized
14 longer case studies in 2010
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Distribution of 25 cases by region
Africa Asia Latin American and the Caribbean
Europe and Eurasia
Middle East
Benin Burundi (2) DRC(2)EthiopiaGhana Kenya (3, 1) RwandaTanzaniaUgandaZambia
Bangladesh Cambodia (2) IndiaPhilippines
BelizeBrazilHonduras
Armenia Egypt
15 5 3 1 1
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Survey results: Purchasing focused on priority services
Maternal health results dominate (22/25). Child health results also top priority (14/25). Infectious (e.g. HIV/AIDS, malaria) and non-
communicable diseases (e.g. cancer screening, diabetes and asthma management) included but less frequent
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Primary care facilities Rural or peri-urban areasCommunity outreachDemand side (users/patients) - vouchers and
transportation subsidies Increasing attempts to reward quality
Survey results: Designs to expand access
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BURUNDI
Public-private purchasing to increase use of priority services and improve quality
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What drove interest in PBF in Burundi?
Facility use rate (consults/year/person) 1 0.47 (2004)
Births attended by qualified staff1 9.8% (2004)
DTP3 immunization1 54% (2004)
Measles immunization1 50% (2004)
Contraceptive prevalence rate2 9% (2005)
U5 sleeping under insecticide-treated net2 8% (2005)
1. Kaneza 2007; 2.http://healthsystems2020.healthsystemsdatabase.org/
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MoFDonors
ProvincialPurchasing
Agency
Health Facilities
$
$Facilities
report utilization
each month
Monthly payments fee for service
+ quarterly bonus for
quality
TechnicalAssistance
HealthNetTPOCordaid
P4P Purchasing – how it works
QualityAssess
Community survey
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Family Planning
0200400600800
1000
months
Fig
ure
s
Target 2006 2007 2008
Number of women using contraceptive methods doubles
Burundi Results – Kibuye Province
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Using P4P to expand access in developing countries
Many different designs Focus on maternal and child health Majority are supply-side (provider) Some are demand-side (user) Clear need for more documentation to learn what is
working and learn how design and implementation challenges are being overcome
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Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane University’s School of Public Health Training Resources Group
Thank you
Reports related to this presentation are available at www.HS2020.org