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Paying Health Care Providers for Performance: Evidence from Rwanda

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Paying Health Care Providers for Performance: Evidence from Rwanda Paul Gertler UC Berkeley January 2009 Prenatal Provider Competency & Quality Baseline Prenatal ... – PowerPoint PPT presentation

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Title: Paying Health Care Providers for Performance: Evidence from Rwanda


1
Paying Health Care Providers for Performance
Evidence from Rwanda
  • Paul Gertler
  • UC Berkeley
  • January 2009

2
Research Team Collaboration
  • Agnes Binagwaho, Rwanda Rwanda MOH
  • Paulin Basinga, National University of Rwanda
  • Jeanine Condo, National University of Rwanda
  • Damien de Walque, World Bank
  • Paul Gertler, UC Berkeley
  • Agnes Soucat, World Bank
  • Jennifer Sturdy, World Bank
  • Christel Vermeersch, World Bank

3
Overview
  • Background/Motivation
  • Rwanda
  • Program Description
  • Evaluation Design and Methodology
  • Baseline Descriptive Statistics
  • Impact of PBF
  • Next Steps

4
Context Developing World
  • Africa
  • Very poor health status
  • Weak health care systems
  • Brain drain doctors nurses leaving
  • Massive AID could be wasted
  • World Wide (WDR 2004)
  • Low Quality of Care
  • Training/technology have had small effect on
    Quality
  • Provider absenteeism high effort low

5
Pay For Performance
  • Pay Providers a bonus based on performance
    measurement
  • Improve quality of care and outcomes
  • Improve job satisfaction retention
  • Implementation Challenges
  • Measuring performance
  • Cheating/Misreporting

6
Rwanda Central African Country
  • 9 million people
  • Genocide in early 1990s
  • GNP per capita 250 US
  • Weak Health Care Infrastructure
  • 36 Hospitals, 369 health centers
  • Doctors 1/50,000 inhabitants
  • Nurses 1/3,900 inhabitants
  • 17 of nurses in rural areas
  • Poor health status, but getting better

7
MDG 4 Infant and child mortality
8
Performance-based Financing (PBF)
  • Local Initiative
  • Objectives
  • Increase quantity quality of health services
    provided
  • Increase health worker motivation
  • Financial incentives to providers to see more
    patients and provide higher quality of care
  • Increased resources
  • Financial incentives
  • Operates through contracts between
  • Government
  • Health facilities providing services

9
Quarterly Payment to Facility i in period t
  • Pj payment per unit of each PBF service j
  • Uijt number of patients using service j in
    facility i in period t
  • Qit facility is quality in period t

10
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11
PBF Facility Quality Score
  • Where Skit facility is Quality index of
    Service k
  • Indicator types
  • Structural Availability of medical
    equipment/drugs needed to deliver adequate
    medical care
  • Process Clinical content of care (CPGs)

12
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13
PNC Quality Indicators
14
PBF Payment
  • Facilities had ability to allocate PBF funds
  • 22 increase in budget
  • 77 to salaries
  • 23 to operating costs, equipment
  • 38 increase in compensation

15
Monitoring Facility Reporting
  • District Comite de Pilotage
  • Approves quarterly payment
  • Based on facility reports independent audits
  • Random utilization audit (once quarterly)
  • One focal point per administrative district
  • Random quality audits (once quarterly)
  • District supervisors based in District Hospital
  • Interview random sample of patients
  • Identify phantom patients
  • MSH study less than 3-5 phantom patients

16
Evaluation Questions Did PBF
  • Increase the quantity of contracted health
    services delivered?
  • Improve the quality of contracted health services
    provided?
  • Improve child health status?

17
Identification Strategy
  • During decentralization, phased rollout at
    district level
  • Identified districts without complete PBF in 2005
  • Group districts into similar pairs based
    on population
    density livelihoods
  • Decentralization reallocated districts
  • Some new districts had PBF in an area of the new
    district
  • Govt rolled PBF to remaining clinics
    (treatments)
  • Districts matched to these partials controls
  • Others randomly assign one to treatment and
    other to control
  • 8 pairs

18
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19
Isolating the incentive effect
  • PBF
  • Performance incentives
  • Additional resources
  • Compensate control facilities with equal
    resources
  • Average of what treatments receive
  • Not linked to performance
  • Money allocated by the health center management

20
Sample Panel 165 Facilities 2006-08
  • 2145 households in catchment areas
  • Random sample of 14 per clinic

21
Survey Content
  • Health Facility Data
  • Financials, Human resources, Equipment, Meds
  • Provider interview for competency (vignette)
  • 8-10 patient exit Interviews for prenatal process
    quality
  • HIMS - utilization
  • General Health Household survey
  • Utilization Health outcomes
  • HIV testing, sexual behavior
  • HIV Positive Household Survey
  • HIV testing, sexual behavior
  • ART, CD4, adherance

22
Research Outline
  • Did we isolate incentives effect?
  • Did we balance T/C groups at baseline?
  • Is PBF associated with increases in
  • Maternal utilization Facility Delivery, Prenatal
    Care
  • Child utilization Preventive care, immunization
  • Process quality of prenatal care
  • Provider prenatal care competency
  • Child health height, weight, anemia, morbidity
  • Did HIV PBF had spillover effects?
  • Did HIV PBF improve access outcomes?
  • Did HIV PBF affect earnings risk behavior?

23
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24
Log Expenditures
  • Randomization balanced baseline
  • Follow-up balanced, so difference in follow-up
    outcomes due to incentives not resources

25
Baseline Balance
  • Utilization (PBF)
  • Structural Quality
  • Availability of staff, equipment drugs
    needed to deliver care (PBF)
  • Little room to improve
  • Process Quality
  • Competency (Vignettes)
  • Process Quality (Patient exit survey)

26
Baseline Expenditures Staffing
27
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28
Impact of PBF Statistical methods
  • Have balance at baseline on all key outcomes
  • Use difference in differences analysis
  • Not a pure randomized experiment
  • Clustered at district-year level
  • Facility Fixed Effects
  • Year dummy
  • Controls age, parity, education, household size,
    health insurance, land, value of assets

29
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30
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31
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32
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33
Prenatal Competency Quality
  • Standardized vignette presented to provider
  • Unprompted responses for competency
  • Measure of ability/knowledge
  • Based on Rwandan Clinical Practice Guidelines
  • Process quality
  • Patient exit interview for process quality
  • Clinical content of care
  • Provider effort

34
Prenatal Provider Competency Quality
35
Baseline Prenatal Provider Competency Quality
36
Quality Conceptual Framework
Production Possibility Frontier
What They Do (Quality)
What They Know (Ability/Technology)
37
Goal Use Pay for Performance to
Close Productivity Gap
PPF
What They Do
Productivity Gap Conditional on Ability
Actual Performance
Ability/Technology
38
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39
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40
Impact of PBF on Prenatal Care Quality
41
Impact of PBF on Provider Knowledge
42
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43
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44
Spillover Effects of HIV/AIDS PBF on Child
Preventive Care
45
Impact of PBF on Child Health (z-scores)
46
Results Summary
  • Balanced at baseline
  • Expenditures same, so isolate incentives
  • Impact on utilization
  • Delivery Child prevention, but not prenatal
  • Impact on prenatal quality
  • Bigger for better doctors
  • Reduced child morbidity Taller children
  • HIV/AIDS Spillover effects

47
Policy
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