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

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

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

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

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

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

MDG 4: Infant and child mortality

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

Quarterly Payment to Facility i in period t P j = payment per unit of each PBF service j U ijt = number of patients using service j in facility i in period t Q it = facility i’s quality in period t

PBF Facility Quality Score Where S kit = facility i ’s 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 )

PNC Quality Indicators

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

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

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

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 Gov’t rolled PBF to remaining clinics (treatments) Districts matched to these partials controls Others: randomly assign one to treatment and other to control 8 pairs

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

Sample: Panel 165 Facilities  2145 households in catchment areas Random sample of 14 per clinic

 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 Survey Content

 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? Research Outline

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

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)

Baseline Expenditures & Staffing

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

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

Prenatal Provider Competency & Quality

Baseline Prenatal Provider Competency & Quality

Quality Conceptual Framework What They Know (Ability/Technology) What They Do: (Quality) Production Possibility Frontier

Goal: Use Pay for Performance to Close Productivity Gap Ability/Technology What They Do PPF Productivity Gap Conditional on Ability Actual Performance

Impact of PBF on Prenatal Care Quality

Impact of PBF on Provider Knowledge

Spillover Effects of HIV/AIDS PBF on Child Preventive Care

Impact of PBF on Child Health (z-scores)

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

Policy