1. “Cash on Delivery” to Improve MCH: Is it Feasible Mead Over Center for Global Development Pay-for-Performance and Performance-Based Aid: at the Crossroads? International Workshop organized by the "Incentives for Health Provider Performance Network" UNIVERSITY OF AUVERGNE- CERDI CLERMONT-FERRAND – FRANCE May 11, 2011

2. Cash on delivery defined

3. Key Features of COD Aid  Rewards improvements in outcomes  Hands-off  Independent verification  Transparency  Complementarity with other aid programs Source: Birdsall&Savedoff (2010) http://www.cgdev.org/section/initiatives/_active/codaid

4. Basic steps of COD Aid 1. Two parties (donor and recipient) negotiate a 2 to 4 year contract specifying that donor will pay $X per HIV infection averted 2. Survey agency collects and reports HIV prevalence data using mutually agreed measurement methods 3. Donor commissions independent audit of measured output 4. Donor pays recipient according to achievement of previously negotiated output performance goals – E.g. $X per HIV infections averted – Government can spend money on ANYTHING (roads, football fields?) 5. Operational or impact evaluation research is strongly encouraged Source: Birdsall&Savedoff (2010) http://www.cgdev.org/section/initiatives/_active/codaid

5. Can it work in the health sector? Consider Maternal Mortality: Maternal mortality is a primary target for Millennium Development Goal 5 Problem is the many health risks are rare: In 2008, between 302,000 and 394,000 women died from maternal causes in LDCs (Hogan and others, 2010) Compares to about 2,000,000 new HIV infections, of which perhaps two/thirds are among women

6. Four Opportunities to capture salient events for an individual woman and her foetus

7. 1. National Pregnancy Registration (Pilot in a district or region)

8. 2. National Birth Regency (Piloted in the same district or region as the preganancy registration)

9. 3. Survey of Previously Registered Pregnant Women

10. 4. Survey of Random Sample of All Households in Region or District of Pregnancy & Birth Registrations

11. Four Opportunities to capture salient events for an individual woman and her foetus

12. Opportunities to capture salient events for an individual woman and her foetus

13. Simulate the number of women in each compartment over time

14. Next steps … Use simulation model to explore sensitivity and specificity of various combinations of the four methods. Propose possible sample contracts

15. www.CGDev.org