1. lR;eso t;rs
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
With Support from
other RCH Divisions 2014
RMNCH+A: Illustrative
Performance Based Incentives for
High Priority Districts (HPDs)
2.
3. i
Preface
High burden of maternal and infant mortality reflects poor development of any society. The
Government of India is committed to reduce this burden, both under MDGs and National
Health Mission (NHM). Several initiatives both at community & facility level have been taken
to accelerate its decline. However the challenge remains in providing the desired services
in geographically isolated, inaccessible and remote areas particularly where the vulnerable
population reside.
Unless there is equity and accessibility in service delivery, we will not be able to reach the
most vulnerable and poor people. Our available human resource and health services are more
polarized to urban than rural areas. One of the main hindrance is the non willingness of
nurses, doctors and specialists to work in the rural and inaccessible areas.
In view of this, the Programme Divisions of this Ministry has worked with the Development
Partners and other stakeholders in preparing suggestive performance based incentives for the
High Priority Districts to motivate and retain critical manpower in these districts. This is an
approach to reach all geographical areas with an intention to accelerate the functioning of
health facilities with priority focus in HPDs. It is my belief that this guideline would be useful
in operationalizing the services and also access to the poor and vulnerable.
(Anuradha Gupta)
AS& MD (NHM)
06.05.2014
4. ii
National Rural Health Mission has contributed to strengthening of health systems including
additional Human Resources for Health (HRH) to provide essential and emergency medical
services. However, there is general view that the services have not improved commensurate
with the increase in HR. One important way to improve productivity and efficiency is to
monitor the performance of service providers, create incentives for them to render high
quantity and quality of desirable services and recognise and reward high performing service
providers. This has been a weakness of large part of our public health delivery system
that there is rather poor performance monitoring and poor accountability towards outputs/
outcomes of the service providers.
It is felt that paying Performance Based Incentives (PBIs) besides the normal salary to the
service providers or their team should lead to significant improvement in output and health
outcomes. The improvement is most urgent in the High Priority Districts (HPDs) and it is
therefore proposed to first implement these PBIs in the HPDs. To help improve the service
delivery, we have designed the PBls so that they should not only help attract critical health
manpower for working in such districts but also retain them and motivate them to perform.
The PBIs have been designed for individual service providers as also for the team, depending
upon whether the individual alone or the team can reasonably ensure the desired outputs/
outcomes. The PBIs require performance particularly on those activities/ interventions which
are most critical to improving outcomes and also indicates the mechanism to measure them.
I am confident, that this document will facilitate the process of improving performance
to achieve the set goals and targets for the different thematic areas under the program by
monitoring and incentivising the performance and recognising the outstanding performers. I
expect all states to use the PBIs particularly in the HPDs.
(Manoj jhalani)
FOREWORD
4th
June 2014
5. iii
Performance Based Incentives (PBIs) for 184 High Priority Districts have been developed by
the Ministry of Health & Family Welfare, Government of India to motivate service providers
to improve their performance particularly those posted at the more peripheral health facilities
(Sub- Centre and Primary Health Centres).
Under the National Health Mission, incentives to service providers for sewing in difficult,
remote and underserved areas and linked to benchmarks of performance have been allowed
based on the State proposals in their annual plans.
However, there has been a felt need for providing guidelines to the States for proposing and
administering these incentives to individual and to teams of service providers.
The Performance Based Incentives have been designed to maximise outputs and outcomes
on key RMNCH+A interventions particularly for critical activities like Emergency Obstetric
Care including C-section and Sick New-Born care which are instrumental in saving many
lives in the labour rooms and special new-born care units.
I am confident that the policymakers and programme managers will make optimal use of
this document to improve performance of service providers and hence the quality of service
delivery at the health facilities particularly in the High Priority Districts.
(Dr Rakesh Kumar)
05.06.2014
Foreword
6. iv
AcknowledgEment
There is a wide gap between the demand and availability of healthcare services and this gap is widening
because our facilities at and below sub district level remain either non-functional or not optimally utilized.
The fact remains that out of total health facilities only about 10% of them are functional when a minimum
performance benchmarking was applied to choose functional health facility which has been designated
as delivery points.
During review and interactions with the state, non-availability of HR, absenteeism, giving equal pay
to both performer and non-performer are identified as some of the demotivating factors resulting in a
situation where our service providers do not want to go to a facility at or below sub-district level.
In view of above challenges, Performance Based Incentives (PBI) for High Priority Districts has been
prepared as a suggestive guideline to improve service delivery and encourage the service providers for
better performance particularly those working at Sub-centres and Primary Health Centres. The PBI also
encourages delivery of critical services such as C-section and saving lives in critical areas such as in
labour rooms, SNCUs etc. This will greatly help in improving accessibility of quality health care in India.
The illustrative framework on performance based incentives is a result of series of discussions and
guidance given by Ms. Anuradha Gupta, Additional Secretary and Mission Director, National Health
Mission, Ministry of Health and Family Welfare, Mr. Manoj Jhalani, Joint Secretary (Policy) and
Dr Rakesh Kumar, Joint Secretary (RCH), National Health Mission.
The contribution of all technical divisions under RCH is highly appreciated. The concentrated effort
rendered by BMGF particularly Dr. Devendra Khandait, Senior Program Officer and the team of experts
at JSI, particularly, Dr. Rajesh Singh, Senior Technical Advisor, Dr. Sebanti Ghosh and Dr. Sudhir
Maknikar, National RMNCH+A Experts were important and has resulted in framing the guidelines after
several revisions of the draft.
I also thank my colleagues Dr. Manisha Malhotra and Dr. Dinesh Baswal and senior consultants
Dr. Pushkar Kumar, Dr. Rajeev Agarwal and Dr. Ravinder Kaur for their valuable inputs and support.
It is expected that the operationalization of 5×5 matrix under RMNCH+A will get boosted with the
implementation of PBI particularly in remote and hilly areas. However, this is flagged that any incentive
should be proposed on the basis of need assessment and not as universal approach even in HPDs.
I sincerely believe this will help and guide the Mission Directors, Program Managers and Service
Providers to focus their attention on performance based indicators for different thematic areas of the
RMNCH+A strategy for desired health outcomes in the coming years.
(Dr. Himanshu Bhushan)
7. RMNCH+A: Illustrative Performance Based Incentives for High Priority Districts (HPDs) v
List of Contributors
1. Ms. Anuradha Gupta, AS&MD (NHM), MoHFW
2. Mr. Manoj Jhalani, JS (Policy), MoHFW
3. Dr. Rakesh Kumar, JS (RCH), MoHFW
4. Dr. Himanshu Bhushan, DC (MH I/C), MoHFW
5. Dr. Manisha Malhotra, DC (MH), MoHFW
6. Dr. Dinesh Baswal, DC (MH), MoHFW
7. Dr. Ajay Khera, DC (CH & Imm I/C), MoHFW
8. Dr. S.K. Sikdar, DC (FP I/C), MoHFW
9. Dr. Haldar, DC (Immunization),MoHFW
10. Dr. P.K. Prabhakar, DC (CH), MoHFW
11. Dr. Sila Deb, DC (CH), MoHFW
12. Dr. Sushma Dureja, DC (AH), MoHFW
13. Dr Devendra Khandait, SPO, BMGF
14. Dr. Rajesh Singh, Senior Technical Adviser, JSI
15. Dr. Sudhir Maknikar, National RMNCH+A Expert, JSI
16. Dr. Sebanti Ghosh, National RMNCH+A Expert, JSI
17. Mr. Niraj Agrawal, Knowledge Management Specialist, JSI
18. Dr. Pushkar Kumar, Lead Consultant, MH, MoHFW
19. Dr. Rajeev Agarwal, Sr. Consultant, MH, MoHFW
20. Dr. Ravinder Kaur, Sr. Consultant, MH, MoHFW
8. RMNCH+A: Illustrative Performance Based Incentives for High Priority Districts (HPDs)vi
List of Abbreviations
ANC Ante Natal Care
ANM Auxiliary Nurse Midwife
AWW Anganwadi Worker
BOH Bad Obstetric History
CHC Community Health Centre
DH District Hospital
EAG Empowered Action Group
EmOC Emergency Obstetric Care
FRU First Referral Unit
GoI Government of India
HMIS Health Management Information System
HPD High Priority District
LSAS Life Saving Anaesthesia Skills
MCTFC Maternal and Child Tracking Facilitation Centre
MCTS Mother and Child Tracking System
MNH Maternal and Neonatal Health
MO Medical Officer
MoHFW Ministry of Health and Family Welfare
NE North East
NHM National Health Mission
OBGYN Obstetrician and Gynaecologist
PBI Performance Based Incentive
PHC Primary Health Centre
PPIUCD Postpartum Intra Uterine Contraceptive Device
RMNCH+A Reproductive, Maternal, Neonatal, Child and Adolescent Health
SBA Skill Birth Attendant
SDH Sub District Hospital
SNCU Special Newborn Care Unit
9. RMNCH+A: Illustrative Performance Based Incentives for High Priority Districts (HPDs) 1
RMNCH+A:
Illustrative Performance Based Incentives for
the 184 High Priority Districts (Hpds)
Introduction
Since the launch of National Rural Health Mission in 2005, there has been a steady but definitive surge in the
demand for services at public health facilities. Within a few years this demand has increased manifold not only
in terms of institutional deliveries but also in Out-Patient Department (OPD) and In-Patient Department (IPD)
services. While assessing the utilisation of health facilities, it has been observed that the demand for health
services has increased at the district and sub-district level, however, at the facilities below sub-district level the
availability and utilization of essential health services is still sub-optimal.
National Health Mission (NHM) is committed to provide accessible, affordable and quality health care to all,
especially the vulnerable and unreached sections of society. Accordingly, ‘reaching those that need it most’ is
the topmost priority under the Reproductive, Maternal, Newborn, Child Health and Adolescent (RMNCH+A)
strategic approach which provides a commitment for continuum of care under NHM.
Government of India (GoI) has identified 184 high priority districts (HPDs) with relatively weak performance
indicators within each state, based on a composite index. These are the districts located in geographical regions
where reproductive, maternal and child morbidity and mortality are high and there is a need for focused planning
to maintain equity and improving access for vulnerable and poor sections of the society. Despite availability of
infrastructure and equipment, one of the gaps assessed in these districts is lack of trained and motivated service
providers at health facilities.
Under the Mission, a provision has been made for allocation of 30% additional funding to each HPD within the
overall state resource envelope. The higher financial allocation for HPDs allows the districts a greater flexibility
to upgrade infrastructure, provide essential drugs and commodities, provide essential amenities for clients and
creatively design performance based incentives for human resources to attract and retain skilled manpower.
In this context, the GoI suggests a framework for providing Performance Based Incentives (PBI) for health service
providers. These would include individual service providers as well as teams of providers giving critical services
at various level of facilities. These additional incentives will not only help in retaining the manpower but also
motivate them to perform better in HPDs. This will further aid in achieving targets and goals under the RMNCH+A
strategy.
Objectives of the PBI scheme
The following are the objectives of the PBI scheme:
• To improve provision and utilization of RMNCH+A services offered to the population;
• To motivate and retain existing health personnel, particularly Auxiliary Nurse Midwife (ANM) and staff
nurses in peripheral areas;
• To increase equity, accessibility and quality of care at the health facility level; and
• To organize health services efficiently.
Monitoring and verification
While implementing any financial scheme it is critical to develop a robust monitoring and verification process.
Verification processes for the PBI scheme would ensure that the reported data accurately reflects the actual
performance both by detecting and correcting misreporting. It is pertinent to note here that these verification
10. RMNCH+A: Illustrative Performance Based Incentives for High Priority Districts (HPDs)2
processes are dynamic and would evolve over time as the scheme moves up in scale and the behaviour of PBI
recipient (such as, service providers, facility teams) change in response to the introduction of financial incentives
and services improve to an optimal level.
The Ministry of Health and Family Welfare (MoHFW), GoI is setting in place strong verification mechanisms to
detect inconsistencies that may result from inaccuracies in data entry and record keeping and/or from improper
implementation by monitoring and evaluation teams. Hence, it is strongly recommended that the state and
district program managers be cautious about imprecise classification of cases, and incorrect use of data collection
tools. The platform of monthly meetings should be used for orienting the supervisors and service providers about
the PBIs and providing clarity on assessing the performance based on the different indicators.
Zero tolerance for irregularities
All states should closely monitor the incentives paid against the performance assessed. High transparency in
both verification procedures and sub-sequent communication of the results is also an important feature of the
verification system.
Any instances of irregularities should not be tolerated particularly in the following areas:
• Excessive provision of unnecessary or potentially harmful services to earn incentives
• Providing false information
• Compromising the quality of care and services
• Denial of services to the eligible beneficiaries
Quality assurance
The PBI scheme makes a large part of the performance-based payments conditional on the progress of indicators
that capture the number of services delivered. The scheme may, for example, reward the providers on the
number of Postpartum Intra Uterine Contraceptive Devices (PPIUCD) inserted, or the number of deliveries
attended at home. While these indicators are relatively easy to measure and verify through facility records,
Health Management Information System (HMIS) and Mother and Child Tracking System (MCTS), they do not
provide insights on the quality of care provided. As much as possible, the PBI should be linked with the quality
of services rendered in comparison with the clinical treatment guidelines or quality standards, such as safe birth
checklist, Maternal and Neonatal Health (MNH) toolkit, infection prevention guidelines etc. This will represent a
unique approach to promote better quality in RMNCH+A services.
Level of verification
Block and district level supervisors will conduct monthly, quarterly, and annual verification of the PBI results
through facility records, HMIS, MCTS, etc. Verification of the results can be done at two levels: at the level of PBI
recipients (do reported numbers reflectthedatain the facilityregisters?) and randomly atthe levelof beneficiaries
(is the data in the registers valid, i.e., have reported services indeed been provided to the beneficiaries?). At
the provider level, it would be easy to verify the results through their records. It is a challenging process to
verify the PBI indicators at the community level. However, this can be explored through the Maternal and Child
Tracking Facilitation Centre (MCTFC) by community client interview done randomly on quarterly basis. The GoI
also suggests block monitoring visit as an additional verification method necessary to extract indicators from
other sources that may not be included in the national HMIS and MCTS databases.
Leveraging technology for the PBI
GoI will explore and develop m-Health software or a web portal that will contain PBI results and outcomes,
financial data, and verification reports. Information and communication technologies (ICT) can be utilized for
data collection as well as for monitoring and evaluation of the PBI activities.
The detailed explanation for each PBI is provided in following pages in a tabular form:
23. lR;eso t;rs
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
With Support from
other RCH Divisions 2014
RMNCH+A: Illustrative
Performance Based Incentives for
High Priority Districts (HPDs)
