April 7, 2011 Alex Ergo, PhD Broad 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 and tracking 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 Aid Payments to national governments conditional on increasing health outputs or achieving impact  Supply-Side Incentives Payments to sub-national levels of government, facilities, teams of health workers, or individual providers, conditional on increasing health outputs or outcomes  Demand-Side Incentives Payments 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 NGOs e.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 services e.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 healthy while avoiding preventable hospitalization and emergency services e.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…    hprn/workinggroups/performance 19

Thank you! wwww.mchip.net Follow us on:

21