More Health for the Money: Lessons from PayforPerformance P4P Initiatives

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More Health for the Money Lessons from
Pay-for-Performance (P4P) Initiatives

• Rena Eichler, PhD
• Broad Branch Associates
• Ruth Levine, PhD
• Center for Global Development

September 11, 2008
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Outline

• What is P4P?
• A taste of evidence
• What are other donors doing?
• Discussion

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What is Pay for Performance or P4P?

• Pay-for-Performance (P4P) is Transfer of money
  or material goods conditional on taking a
  measurable health related action or achieving a
  predetermined performance target
• Financial risk is the assumed driver of change
• From the Center for Global Development Working
  Group on Performance-Based Incentives

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Examples

• Payment to providers (individual health workers,
  service providing institutions) and sub national
  levels of government linked to attainment of
  predetermined results.
• Federal to province transfers (Argentina)
• Province-wide NGO umbrella service delivery
  contracts (Afghanistan, DRC)
• Contracts from donors and/or government to
  service delivery NGOs (Haiti, Afghanistan)
• Contracts from government to public, nonprofit
  and for profit service providers (Rwanda)
• Payment to patients or household decisionmakers
  linked to evidence of compliance with pre-set
  conditions
• Conditional cash transfers (Mexico, Nicaragua)
• Enablers in TB programs (Russia)

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Why paying for results is gaining attention in
global health

• Global concern about achieving the health
  Millennium Development Goals
• Business as usual solutions have not adequately
  addressed dysfunctional incentive environments
  at all levels of health systems
• Belief that getting the incentives right might
  be the needed complement to money, technical and
  capacity building interventions
• Impressive gains have been observed in some
  applications of P4P

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What health systems problems is P4P addressing?

• Increasing utilization
• Overcoming financial and physical barriers to
  access that poor households face
• Overcoming information and cultural barriers that
  inhibit utilization
• Strengthening capacity to provide services
• Catalyzes changes that strengthen management.
• Improves information systems and the use of
  information for decisions.
• Motivates health workers.
• Improving quality
• Preventive care services utilized by more people
• Rewards correct diagnosis and treatment
• Improving efficiency
• Better use of inputs to achieve health results

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Lets begin in a typical rural health center
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Are financial incentives the needed motivator ?
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Why the changed payment method can motivate
improved performance

• The push Financial risk (potential to lose the
  withheld amount) provides incentives to achieve
  performance targets
• The pull Opportunity to earn the bonus
  provides strong incentives to achieve performance
  targets
• Some documented changes inspired by P4P and
  implemented from the bottom up
• Management focus on results
• Better use of information for management
  decisions
• More motivated staff
• Effective outreach to challenging populations
• More efficient and effective use of inputs
• Strategic requests for technical assistance

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Intrinsic vs. extrinsic motivation

• People are motivated by intrinsic forces
• e.g., professional pride, altruism
• And by extrinsic forces
• e.g. money, recognition, awards
• P4P focuses on extrinsic motivation payment
  comes from an external source
• Aim is to motivate with extrinsic rewards in a
  way that reinforces intrinsic motivation

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Possible pitfalls

• Excessive attention to reaching targets, to
  detriment of other (harder to measure) types of
  performance
• Undermining of intrinsic motivation, turning
  health care delivery into piecework
• Gaming, including erosion in quality of
  institutions service statistics

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Design elements and implementation considerations

• Agreed indicators
• Small number is best (lt10?)
• Agreed on targets
• Relative to own baseline
• Agreed reward (or penalty) linked to attainment
  of target
• Agreed way to measure and validate
• Additional penalties for evidence of misreporting

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Consider the new management and systems needed.

• Consider the new roles assumed by each level in a
  health system.
• Consider the role of information and need to
  strengthen its quality and use.
• Consider the training needs to explain the new
  system.
• Consider the new ways money will flow and new
  rules about who controls funds and how they can
  be used.
• Consider what is required to assure that reported
  results are valid.
• Consider the increased demands for technical
  assistance that may arise when facilities and
  districts want to reach performance goals.

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Haiti Significant increase in immunizations and
attended deliveries under P4P.

• P4P is associated with a 13 to 24 percentage
  point increase in immunization coverage.
  Translates to 15,000 additional children per
  contract period immunized because of P4P.
• P4P is associated with a 19 to 27 percentage
  point increase in institutional deliveries.
  Implies that 18,000 additional women per
  contract period gave birth more safely because of
  P4P.
• Source Rena Eichler, Paul Auxila, Uder Antoine,
  and Bernateau Desmangles, September 2006. Center
  for Global Development Working Group on
  Performance-Based Incentives

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Rwanda Provinces with Performance Based Payment
saw bigger improvements than those
without.Source Miriam Schneidman and Louis
Rusa, October, 2006. Center for Global
Development Working Group on Performance-Based
Incentives
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Argentinas Plan Nacer

• Federal to province level transfers are based on
• Number of poor women and children enrolled in a
  social insurance program (60)
• Performance on key output measures (40)
• Indicators
• Maternal Health Antenatal care, Anti-tetanus
  vaccine, reproductive care consults
• Child Health Measles and DPT3 vaccine up, normal
  child development consultations
• Newborn health Proportion of newborns weighing
  more than 2,500 g
• Systems performance agreements successfully
  implemented, of providers under annual
  performance agreements, trazadora targets
  achieved by the provinces in the last billing
  period
• Results More than half million poor mothers and
  children are enrolled, infant mortality has
  dropped, and utilization of 7 tracer services
  has increased.

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What to expect

• Time limited measurable interventions respond
  quickly.
• Immunizations, vitamin A, generic curative care
  visits, deliveries.
• Extended duration, time limited interventions
  take longer to show results- but results do come.
• Prenatal care, tuberculosis treatment completion
• Chronic conditions requiring considerable
  lifestyle change pose the toughest challenge- but
  evidence suggests promise.
• ART, diabetes, hypertension

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How donors can lead, collaborate, contribute to
making P4P effective

• Country level
• Provide much needed technical assistance to
  design, implement and ongoing operationalize.
• Support development of adaptable tools, guides,
  etc .
• Support evaluation to increase knowledge.
• Regional Level
• Regional level workshops to train and enable
  sharing.
• Support development of regional TA capacity.
• Global level
• Strategic engagement with donors to complement
  and influence (ex IWG)..
• Demonstrate added value of TA.
• Global knowledge sharing.

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A taste of what other donors are doing

• USAID has supported large scale P4P in Haiti and
  Rwanda and smaller programs in Kenya and DRC.
• Results-based financing is part of World Bank HNP
  strategy.
• Multi-donor trust fund to the World Bank to
  implement and evaluate pilots in 9 countries
  (105 million from Norway).
• Norway bilateral support of RBF for MNCH in
  India, Nigeria, Pakistan and Tanzania.
• Inter-Agency Working Group, co-led by CGD and
  World Bank.
• AUSAID
• EC
• GAVI HSS window can be used for P4P (ex
  Afghanistan).
• Global Fund

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Challenges at country level

• P4P is fashionable and moving but
• Dearth of expertise to provide sound assistance.
• Bad design and faulty implementation could sink a
  potentially powerful strategy.
• Donors under-fund and under-appreciate the
  importance of strengthening management and
  implementation.
• Existing systems need reform and strengthening in
  most (all?) settings
• Information systems are weak
• Financial management rules/regs often conflict
  with P4P.
• Government capacity weak at all levels.
• Training is required to roll out new schemes
  (often under-funded)
• If they dont understand it, they wont respond
  to new incentives.

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Challenges at the global level

• Perception that P4P conflicts with Paris
  Declaration.
• Concern by some that financial incentives dont
  belong in health.
• Move toward pooled funding (SWAp and budget
  support) may lead to less technical assistance
  through other donor support mechanisms.
• Decentralized structures in many donor
  organizations that limit donor-wide strategy.

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Thank you