Publication: Incentivizing Quantity and Quality of Care: Evidence from an Impact Evaluation of Performance-Based Financing in the Health Sector in Tajikistan
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2022-02
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2022-02-18
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To improve utilization and quality of health services, a growing number of low- and middle-income countries have been experimenting with financial incentives tied to providers’ performance. Relying on a difference-in-differences approach, we estimate the impacts of the performance-based financing pilot in Tajikistan. Primary care facilities were given financial incentives conditional on the quality and quantity of selected services. Significant improvements are found on quality indicators, including elements of the content of care. While the communities in the pilot districts reported higher satisfaction with the local primary care facilities, and despite the improvements in quality, the impact on utilization was limited.
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Publication Incentivizing Quantity and Quality of Care(World Bank, Washington, DC, 2019-07)This paper presents the results of an impact evaluation of a performance-based financing pilot in rural areas of two regions of Tajikistan. Primary care facilities were given financial incentives conditional on general quality and the quantity provided of selected services related to reproductive, maternal and child health, and hypertension-related services. The study relies on a difference-in-difference design and large-scale household and facility-based surveys conducted before the launch of the pilot in 2015 and after three years of implementation. The performance-based financing pilot had positive impacts on quality of care. Significant impacts are measured on facility infrastructure, infection prevention and control standards, availability of equipment and medical supplies, provider competency, provider satisfaction, and even some elements of the content of care, measured through direct observations of provider-patient interactions. While the communities in the performance-based financing districts reported higher satisfaction with the local primary care facilities, and despite the improvements in quality, the findings suggest moderate effects on utilization: among the incentivized utilization indicators, only timely postnatal care and blood pressure measurements for adults were significantly impacted.Publication Looking into the performance-based financing black box(Oxford University Press, 2021-07)Performance-based financing (PBF) is a complex health systems intervention aimed at improving the coverage and quality of care. 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In terms of quality, PBF increased the availability of inputs and equipment, qualified health workers, led to a reduction in formal and informal user fees but did not affect the content of care. However, for many positively impacted outcomes, the differences between the PBF group and the group receiving additional financing not linked to performance are not significant, suggesting that additional funding rather than the explicit incentives might be driving improvements. In contrast, the intervention group offering enhanced supervision, coaching and monitoring without additional funding did not experience significant impacts compared to the control group.Publication Financial Incentives to Increase Utilization of Reproductive, Maternal, and Child Health Services in Low- and Middle-Income Countries(World Bank, Washington, DC, 2021-10)Financial incentives for health providers and households are increasingly used to improve reproductive, maternal, and child health service coverage in low- and middle-income countries. This study provides a quantitative synthesis of their effectiveness. A systematic review was conducted of the effects of performance-based financing, voucher, and conditional cash transfer programs on six reproductive, maternal, and child health service indicators, with eligible evidence coming from randomized controlled trials and studies using double-difference, instrumental variables, and regression discontinuity designs. Four literature searches were conducted between September 2016 and March 2021 using seven academic databases, Google Scholar, development agency and think tank websites, and previous systematic reviews. Random effects meta-analysis was used to obtain mean effect sizes. From 58 eligible references 212 impact estimates were extracted, which were synthesized into 130 program-specific effect sizes. Financial incentives increase coverage of all considered reproductive, maternal, and child health indicators, but mean effects sizes are of modest magnitude. Effect size heterogeneity is typically low to moderate, and there is no indication that study bias risk, baseline indicator levels, or a combination of provider- and household-level incentives impact effect sizes. 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Fifty-eight health zones in six provinces were randomly assigned to either a control group (28 zones) in which facilities received unconditional transfers or to a PBF program (30 zones) that started at the end of 2016. Follow-up data collection took place in 2021–2022 and included health facility assessments, health worker interviews, direct observations of consultations and deliveries, patient exit interviews, and household surveys. Using multivariate regression models, we estimated the impact of the program on 55 outcomes in seven health system domains: structural quality, technical process quality, non-technical process quality, service fees, facility management, providers’ satisfaction, and service coverage. We used random-effects meta-analysis to generate pooled average estimates within each domain. The PBF program improved the structural quality of health facilities by 4 percentage points (ppts) (95% CI 0.01–0.08), technical process quality by 5 ppts (0.03–0.07), and non-technical process by 2 ppts (0–0.04). PBF also increased coverage of priority health services by 3 ppts (0.02–0.04). Improvements were also observed for facility management (9 ppts, 0.04–0.15), service fee policies, and users’ satisfaction with service affordability (14 ppts, 0.07–0.20). Service fees and health workers’ satisfaction were not affected by the program. The results suggest that well-designed PBF programs can lead to improvements in most health systems domains relative to comparable unconditional financing. However, the large persisting gaps suggest that additional changes, such as allocating more resources to the health system and reforming the human resources for health management, will be necessary in DRC to achieve the ambitious global universal health coverage and mortality goals.Publication Using Provider Performance Incentives to Increase HIV Testing and Counseling Services in Rwanda(Elsevier, 2014-12-12)Paying for performance provides financial rewards to medical care providers for improvements in performance measured by utilization and quality of care indicators. In 2006, Rwanda began a pay for performance scheme to improve health services delivery, including HIV/AIDS services. Using a prospective quasi-experimental design, this study examines the scheme's impact on individual and couples HIV testing. We find a positive impact of pay for performance on HIV testing among married individuals (10.2 percentage points increase). Paying for performance also increased testing by both partners by 14.7 percentage point among discordant couples in which only one of the partners is an AIDS patient.
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