Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane Universitys School of Public Health Training Resources Group Pay for Performance (P4P) to achieve health results: What are countries doing and how are they doing it? Alix Beith, Catherine Connor, Rena Eichler, Natasha Hsi and Katie Senauer November 30, 2009

Presentation Objectives To briefly discuss the P4P concept and why it has generated much recent global interest To share findings from an online survey of why countries are using P4P To provide a taste of less-known cases to highlight the diversity of goals and approaches

AN INTRO TO P4P

What is Pay-for-Performance (P4P)? Supply-side payments to sub national levels of government, facilities, teams of health workers, or individual providers, conditional on increasing health outputs and/or quality (not processes). Demand-side payments to individuals, households or communities, conditional on engaging in pre-agreed healthy behaviors. P4P and Results based financing often used interchangeably.

Formal Definition 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. No results, no payment. *From the Center for Global Development Working Group on Performance- Based Incentives

Why paying for results is gaining attention in global health Global concern that 2015 health MDGs will not be met 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 It is a potentially powerful health systems strengthening strategy Donor support building: AusAID, DFID, Gates Foundation, Norway, USAID, World Bank

LEARNING FROM THE SURVEY

Why did HS2020 launch a P4P survey? To increase information about a burgeoning number of little known P4P cases. Beyond LAC Conditional Cash Transfers, Afghanistan, Haiti, and Rwanda. To fill the gap between growing experimentation and little documentation To focus on design, stakeholder process, and implementation nuts and bolts, as well as results

Snapshot of Online Survey Online survey live from April 21-May 25, e-responses received 20 complete enough for analysis 8 respondents received a P4P reward (US $200) for completeness and richness of response

Where? Distribution of 20 responses plus 5 invited cases by region AfricaAsiaLatin American and the Caribbean Europe and Eurasia Middle East Benin Burundi (2) DRC(2) Ethiopia Ghana Kenya (3, 1) Rwanda Tanzania Uganda Zambia Bangladesh Cambodia (2) India Philippines Belize Brazil Honduras ArmeniaEgypt

Snapshot of Findings Maternal health dominates (22/25). Child health also top priority (14/25). Infectious (e.g. HIV/AIDS, malaria, STDs) and non- communicable diseases (e.g. cancer screening, diabetes and asthma management) also included but less prominent Scheme implementers are primarily developing country actors (usually MoH or NGOs, sometimes health insurance bodies)

Snapshot of Findings Support often from donors, but donors do not seem to be in driving role Most involve supply side (service provider level) incentives. Some also involve demand side (users) such as vouchers and transportation subsidies. Indicators usually are service utilization measures, increasing attempts to incorporate quality measures See full report at:

COUNTRY-SPECIFIC SNAPSHOTS

We are developing case study reports of 17 P4P experiences in… Benin Belize Brazil Burundi Cambodia DRC Egypt Ethiopia India Kenya (2) Pakistan Philippines (2) Tanzania Uganda Zambia Here are a few country-specific examples of what we are learning…

BURUNDI NGO pilots and lessons from neighboring Rwanda inform nationwide GoB-led P4P scale-up

Key features of piloting P4P in Burundi (Gitega province) Goal: Reduce maternal mortality, child malnutrition, U5 mortality, and prevent and treat HIV/AIDS. Supply side P4P: Monthly: Public and NGO facilities are paid fees for providing specified services: immunizations, antenatal care, deliveries, referrals for deliveries needing emergency care, family planning, maternal and child health services, HIV testing, PMTCT, TB, etc. Quarterly: Quality bonus of up to 15% of sum of fees earned in the previous quarter (based on assessment of 154 indicators). Allocation: 50% to facility, 50% to staff. * Autonomy to determine what to invest in and how to share payments among staff

Implementation arrangements Facilities report quantities of rewarded services delivered each month to the district management team which reports to the Provincial steering committee. Provincial steering committee is headed by someone from the provincial administration (not necessarily with a health background) and is comprised of health facility and community representatives. Provincial steering committee validates reported data, and tells Provincial purchasing agency to transfer earned amounts to facility bank accounts.

NGO pilots and nation-wide public sector P4P scale-up NGOs have been piloting P4P schemes since 2006 Pilot schemes (blue areas) cover ~ 880,000 people Nascent scale-up areas (brown areas) cover ~2.5 million Aim to cover entire country by early 2010

Initial results and lessons Results: Significant increases in curative care visits, immunization coverage, family planning utilization, and institutional deliveries – in Gitega average 50-60% increase Increased productivity and efficiency (same staff produce more services). Improved health center management : all develop business plans on which contracts are based, all monitor service statistics. Strengthened health management information system. Increased community involvement. Lessons for others: Intra-country dynamics matter: P4P in part of the country attracted providers from non-P4P areas. P4P can help increase service utilization in post-conflict countries

BRAZIL Two-pronged P4P: hospital accreditation and disease management

Key features of UNIMED-BH in Brazil UNIMED-Belo Horizonte (UBH) is a non-profit health insurance company covering 800,000 beneficiaries (39% market share) UBH is also a medical cooperative - 4,700 physician members UBH owns and operates seven facilities and contracts an additional 258 (hospitals, laboratories and clinics)

Key features of UBHs two P4P schemes Hospital Accreditation (2005) Pay hospitals for initiating and completing the accreditation process (ONA or ISO) Payments ranged from 7- 15% of hospital per diem rates based on level achieved Disease management (2006) Diabetes, cardiovascular, child asthma Incentive payments to individual doctors: Extra 37% on FFS for enrolling patients in disease management programs and following protocols End of year bonus of $30 per patient for reaching pre-defined clinical outcome targets

Initial Results by 2009 Hospital Accreditation (2005) 19 of the 45 network hospitals were accredited, accounting for 69% of all UBH hospital admissions UBH is currently the health plan with the highest number of accredited hospitals in Brazil Disease management (2006) Indicatorbeforeafter Cardio: BP <140/ Diabetes: Hb glucose <7% Child asthma: hospital admissions 225

Lessons Clearly distinguish P4P from other initiatives that increase provider remuneration so that providers link the incentive payment with performance Involve specialties to set clinical indicators Disseminate P4P results to providers to enhance understanding Pay an annual bonus based on clinical results, in addition to fee-for-service, so physicians can correct their activities during the year in order to earn the bonus

KENYA Using vouchers and provider payments to boost utilization of safe motherhood and family planning services

Key features of P4P in Kenya Goals: Reduce maternal mortality by increasing facility based deliveries and family planning. Strategy: Voucher program that subsidizes the cost of care to users and pays fees to public and private providers. Demand-side : Poor women can purchase vouchers (subsidized rate) that entitle them to receive safe motherhood and family planning services from accredited private and public providers. Supply Side: Public and private providers receive fees (uniform across sectors) to provide safe motherhood and FP services. Pilot launched in June 2006 in 3 rural districts and 2 urban slums (covering 3 million). Plans to implement in more regions.

Implementation structure

Pilot Program: Actual vs. Anticipated Results ( )

Lessons Vouchers are a mechanism to target the poor. Consider whether voucher marketers have incentives to sell/give vouchers to ineligible (non-poor) users. Vouchers appear to stimulate demand when the barrier is financial (facility deliveries increased). When barriers include other issues (e.g. stigma, preferences, lack of understanding), vouchers alone will not significantly increase demand (family planning performance was disappointing). Vouchers give purchasing power to consumers- as they can vote with their feet. Critical to get the prices right: higher fee to providers for C-sections resulted in 17% C-section rate. Management costs are considerable.

BELIZE Using supply-side P4P to strengthen health prevention activities with national social insurer as payer

Key features of P4P in Belize Goal: Strengthen primary care, quality, and productivity. Specific focus on postnatal care, diabetes and hypertension. Supply Side P4P: a financial incentive is received by health institutions (centers or hospitals) for full or partial attainment of targets. 9 indicators: 8 process (controls on drug prescribing and imaging, medical records and reporting, productivity) and 1 consumer satisfaction. Maximum potential payment: # people registered at health center * per capita payment Implementation arrangements: National Health Insurance (NHI) body (part of Social Security Board and not MOH), monitors and validates results, and transfers payment to the facilities.

Results Implemented in 2001, P4P currently covers 41% of pop. The rest of the population is clamoring to be registered with an NHI – paid clinic, as they are perceived to provide better quality service with greater access to medicines. Author reports that region with highest maternal deaths now reports none. Author reports that many people who had never consulted with a general practitioner now access care from NHI- paid centers.

Next steps and lessons Next steps: Plan to revise indicators to reflect health outcomes (outputs). Considering demand side incentives. Considering sin taxes, higher income taxes, and increasing social security contributions to finance expansion. Some lessons: Rewarding process measures incentivized referrals to higher levels of care. Political support is weakening- unclear future.

PAKISTAN Using vouchers to improve access to and utilization of RH services in a social franchise.

Key features of P4P in Pakistan Goal: To reduce maternal and infant mortality by increasing utilization of antenatal care, skilled delivery and postnatal care and family planning. Strategy: Overcome financial and social barriers to accessing safe motherhood services by providing health education, vouchers for free care, transportation funds, and payment to private providers in a network (social franchise) to serve this underserved group. Demand side: Poor women who have never delivered in a health facility are sold vouchers at a highly subsidized price which entitles them to FP, antenatal care, delivery, postnatal care delivered by accredited providers who are part of the GoodLife network. When women redeem vouchers to access care, providers give them funds to cover transportation costs. Supply Side : Private providers in the Goodlife network receive training and benefit from demand generation from marketing and voucher reimbursements.

Dera Ghazi (DG) Khan District Pilot ( , 18 months) Since voucher introduction: Increase from 0 to 95% deliveries with skilled providers among poor women who had never previously received antenatal care or delivered in a health facility.

Deliveries among voucher recipients (n= 1999)

Family Planning results among voucher clients (n=1569)

Lessons Challenge to ensure enough demand to maintain provider interest in participating. Quality of care by providers varies - need strategy to assure quality care. Challenge to manage a growing network. Must consider a plan for large-scale administration and support. Payment must be timely - especially if providers advance payment for transportation. Consider adding a completion bonus if a voucher recipient receives all services - to provide incentives to providers for outreach and follow up.

Additional lessons from other cases Bring in key players (and possible P4P opposition), such as health worker unions, who are critical to generating scheme buy-in, early (Benin) Anticipate during the design phase that P4P can skew provider behavior away from actions that are not rewarded (Egypt) Ensure that service supply and quality are ready to meet the demand stimulated by P4P incentives, or P4P will not result in desired impact (India). P4P and civil service regulations: P4P may be difficult to implement within rigid civil service regulations P4P may spur civil service reforms Civil service reforms may delay introduction of P4P (Ethiopia).

In summary… P4P experiments are being implemented in many different shapes and forms: Across regions Across sectors (public, private, both) Across disease areas, with a predominant focus on maternal and child health concerns Principally supply-side interventions, but some incorporate a demand-side component and a few are purely demand-side There is a clear need for more documentation: to learn what is working and how design and implementation challenges are being overcome

Our teams immediate plans… To finalize the country-specific case studies (by end 2009) To undertake a series of policy-oriented cross-country cases (in early 2010). Possible topics include: Health concern-specific cases (e.g., maternal health, child health, family planning etc.) Region-specific cases (e.g., how P4P is being used in Africa) Technical aspects of design and implementation (e.g., developing indicators and targets, establishing payment rules etc.) All will be posted on the HS20/20 website once available

We invite you to join the PBIN The Performance-Based Incentives Network (PBIN): A place where people post papers, news, and share information on performance based incentives Composed of a wide range of participants from country ministries, academics and donors To join, please add your name/ to sign up list with Erica James or For more on our work program, please Rena Eichler on

Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane Universitys School of Public Health Training Resources Group Thank you Reports related to this presentation are available at