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Provider Response to Quality
Incentives and Targets in
Senegal
Presenter: April Williamson, Program Officer, R4D
Payment f...
Study of Enhanced Quality of Care Assessment Instruments in
Senegal’s Performance-Based Financing Program
Duration: 2015-2...
This study was funded by the United States Agency
for International Development under Translating
Research into Action, Co...
Study Context
• 2012: Performance-Based Financing (PBF) program piloted in
Kaffrine and Kolda regions; 2015 expansion to 4...
Study Objectives
• Correspond to identified needs from 2013
Review & Revision
1. Improve primary-level quality checklists
...
The “Black Box”
“Black Box” Study Component
Objectives
• Conduct an in-depth study on the “black box”
of how and why providers respond to ...
Literature Review
• Existing literature on PBF programs and quality
is limited
• The “black box” of provider behavior iden...
Literature Review (cont.)
• But…
– Most studies did not include an explicit focus on
provider behavior
• Evidence is anecd...
Anecdotal Evidence from Senegal
• Source:
– Evaluation du processus du projet financement basé sur les
résultats dans le s...
Senegal’s Quality Scores
12/8/2015 11
Highest scores
•Lab services
•Family planning
•Vaccination and
newborn care
Lowest s...
Anecdotal Findings on Provider Behavior
• Greater staff involvement
– More autonomy, accountability, and active management...
Anecdotal Findings on Provider Behavior
• Use of PBF payments
– Used for personnel bonuses and facility and service
improv...
Enabling and Constraining Factors
12/8/2015 14
Enabling Factors
• Equipment and skills available for lab tests and family ...
Quality Scores – Quality Area
12/8/2015 15
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20...
Quality Scores – Quality Area
12/8/2015 16
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50.00%
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20...
Quality Scores – Quality Area
12/8/2015 17
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
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70.00%
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20...
Quality Scores – Quality Area
12/8/2015 18
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20...
Hypotheses
– Be capable of obtaining
better quality scores where
improvement is within their
control
– Take advantage of
a...
Hypotheses
– Be capable of obtaining
better quality scores where
improvement is within their
control
– Take advantage of
a...
Methodology
12/8/2015 21
• Qualitative study
• Individual interviews and focus group discussions
with providers in interve...
Methodology
12/8/2015 22
Individual
Interview
Providers under
RBF programs
(intervention
Zone)
Providers not yet
exposed t...
Data Collection Instruments
12/8/2015 23
• Behaviors
– Open-ended -> prompted questions
– Prioritization of activities to ...
Timeline
• May – June 2015: Award received; protocol
development; literature review
• August 2015: KIT ethical approval
• ...
Indicative Findings from Instrument
Testing
• Biggest benefits of PBF in terms of quality
– Focus on important elements of...
Indicative Findings from Instrument
Testing
• Most important activities to achieve quality
– Ensuring availability of equi...
Thank you!
EXTRA SLIDES
Quality Scores– (DS Kaffrine)
12/8/2015 29
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Ge...
Quality Scores– (DS Kolda)
12/8/2015 30
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Gener...
Quality Scores – by district
12/8/2015 31
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BIR...
Quality Scores- by region
12/8/2015 32
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90.00%
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KAFFRI...
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Providers Response to Quality Incentives and targets in Senegal

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April williamson

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Providers Response to Quality Incentives and targets in Senegal

  1. 1. Provider Response to Quality Incentives and Targets in Senegal Presenter: April Williamson, Program Officer, R4D Payment for Performance: A Health Systems Perspective A workshop for scientists and practitioners Dar es Salaam, Tanzania 12/8/2015
  2. 2. Study of Enhanced Quality of Care Assessment Instruments in Senegal’s Performance-Based Financing Program Duration: 2015-2016 Location: Senegal (Dakar; Kaffrine, Kolda, and 1 other region [TBD]) Research team: • Co-Principal Investigators: Marty Makinen, Results for Development (R4D); Jurrien Toonen, Netherlands Royal Tropical Institute (KIT) • April Williamson and Emily Allen (R4D); Christel Jansen (KIT); Famory Fofana (KIT) Key partners: • Senegal’s MoH • USAID/Senegal's HSS project (Abt Associates) • World Bank Financial and technical support: • USAID’s Translating Research into Action (TRAction) 12/8/2015 2
  3. 3. This study was funded by the United States Agency for International Development under Translating Research into Action, Cooperative Agreement No. GHS-A-00-09-00015-00. This study is made possible by the support of the American People through the United States Agency for International Development (USAID). The findings of this study are the sole responsibility of R4D/KIT and do not necessarily reflect the views of USAID or the United States Government.
  4. 4. Study Context • 2012: Performance-Based Financing (PBF) program piloted in Kaffrine and Kolda regions; 2015 expansion to 4 new regions – Quality checklists are used to deflate bonus payments for quantity results • 2013: Review and Revision of the PBF program concluded that there was a need to: – Improve the primary-level (Health Post/Health Center) quality checklists – Develop a quality checklist for the hospital level – Better understand how provider behavior changes in response to the quality checklists • 2015: USAID process evaluation provided some initial findings on provider behavior, but further study is still needed 12/8/2015 4
  5. 5. Study Objectives • Correspond to identified needs from 2013 Review & Revision 1. Improve primary-level quality checklists 2. Develop quality checklist for the hospital level 3. Explore “black box” of provider behavior in response to quality checklists 4. Provide recommendations based on the above 5. Contribute to the knowledge base on quality assessment mechanisms for PBF 12/8/2015 5
  6. 6. The “Black Box”
  7. 7. “Black Box” Study Component Objectives • Conduct an in-depth study on the “black box” of how and why providers respond to quality incentives – Beyond focusing on quality scores • Identify possible complements to facilitate quality improvements • Provide recommendations for improvements to the program’s quality component 12/8/2015 7
  8. 8. Literature Review • Existing literature on PBF programs and quality is limited • The “black box” of provider behavior identified as an area where further study is needed • Some anecdotal evidence that PBF programs can lead to improved provider behavior – Greater autonomy and accountability – Increased productivity and motivation – More collaboration within structures (but not between health systems levels) 12/8/2015 8
  9. 9. Literature Review (cont.) • But… – Most studies did not include an explicit focus on provider behavior • Evidence is anecdotal, not systematic – Evidence is mixed on the effects of quality incentives – Mechanisms for quality improvement are not systematically explored 12/8/2015 9
  10. 10. Anecdotal Evidence from Senegal • Source: – Evaluation du processus du projet financement basé sur les résultats dans le secteur de la santé au Sénégal - 2015 (USAID/Senegal’s HSS Project [Abt Associates], MoH) • Objective of the evaluation: – Document the PBF program’s process of implementation, initial results, and challenges 08/12/2015 10
  11. 11. Senegal’s Quality Scores 12/8/2015 11 Highest scores •Lab services •Family planning •Vaccination and newborn care Lowest scores •M&E/HIS •Maternal care •Infectious diseases
  12. 12. Anecdotal Findings on Provider Behavior • Greater staff involvement – More autonomy, accountability, and active management – More respect for working hours and reduced absenteeism • Quality improvement – Greater adherence to norms, protocols, and hygiene standards – More attention to customer care • Organization and management – More systematic planning and implementation of activities, including regular monthly coordination meetings – Better management of data, including emphasis on drug supply to avoid stock-outs 12/8/2015 12
  13. 13. Anecdotal Findings on Provider Behavior • Use of PBF payments – Used for personnel bonuses and facility and service improvements (e.g. strengthening equipment and supplies; improvement to the physical structure) • Innovative strategies – Addressing issues that reduce use of certain services (ex: use of loudspeakers to inform populations about scheduled services) • Greater attention paid to users – Interest in meeting the needs and wants of populations served 12/8/2015 13
  14. 14. Enabling and Constraining Factors 12/8/2015 14 Enabling Factors • Equipment and skills available for lab tests and family planning • Assistance from other projects/programs Constraining Factors • Lack of availability of equipment and supplies for maternal care • Difficulty holding monthly meetings and managing information for M&E • Insufficient training, weak support from District Management Teams, and insufficient supervision concerning certain areas • Human resources shortages and absences (ex: off-site trainings and meetings for nurses in charge of Health Posts)
  15. 15. Quality Scores – Quality Area 12/8/2015 15 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% 2013 2014
  16. 16. Quality Scores – Quality Area 12/8/2015 16 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% 2013 2014 Note that no indicator reaches 100%
  17. 17. Quality Scores – Quality Area 12/8/2015 17 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% 2013 2014 Biggest improvement in infectious diseases
  18. 18. Quality Scores – Quality Area 12/8/2015 18 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% 2013 2014 Only decline in hygiene & sterilization Improvement in almost every area; biggest improvements to weakest scores
  19. 19. Hypotheses – Be capable of obtaining better quality scores where improvement is within their control – Take advantage of available tools and approaches – Show entrepreneurship and creativity – Respond to user needs and wants – Use PBF bonus payments to improve quality – Look for tools, advice, and financing to improve quality – Be more aware of quality in their work – Plan based on outcomes, rather than inputs – Know what they’re accountable for – Be limited by supplies and equipment available 12/8/2015 19 • Provider personnel under the PBF program’s quality checklists will:
  20. 20. Hypotheses – Be capable of obtaining better quality scores where improvement is within their control – Take advantage of available tools and approaches – Show entrepreneurship and creativity – Respond to user needs and wants – Use PBF bonus payments to improve quality – Look for tools, advice, and financing to improve quality – Be more aware of quality in their work – Plan based on outcomes, rather than inputs – Know what they’re accountable for – Be limited by supplies and equipment available 12/8/2015 20 • Provider personnel under the PBF program’s quality checklists will:
  21. 21. Methodology 12/8/2015 21 • Qualitative study • Individual interviews and focus group discussions with providers in intervention (PBF) and control (non-PBF) areas • Three key themes: – Behavior to attain quality results – Enabling/constraining factors – Attitudes toward quality • Emphasis on essential obstetric and neonatal care (EONC)
  22. 22. Methodology 12/8/2015 22 Individual Interview Providers under RBF programs (intervention Zone) Providers not yet exposed to RBF (Control Zone) Focus Group Discussions (FGDs) Providers under RBF programs (intervention Zone) Providers not yet exposed to RBF (Control Zone) Semi-structured questions focused on individual behavior More open- ended questions focused on the facility team Evaluate changes in behavior and practices, resource and tools utilization, and provider attitudes, as well as facilitating/constraining factors (all relating to quality)
  23. 23. Data Collection Instruments 12/8/2015 23 • Behaviors – Open-ended -> prompted questions – Prioritization of activities to improve quality (e.g. soliciting users’ perspectives; using available tools/resources/information and seeking new ones; developed plans) – Consequences to performance (positive & negative) • Factors – Prioritization of constraints (e.g. lack of material or financial resources, tools, supervision) – Technical supervision – Explanation for highest/lowest/most improved quality scores • Attitudes – Prioritization of dimensions of quality – Benefits and drawbacks of RBF – Assessment of the quality checklist
  24. 24. Timeline • May – June 2015: Award received; protocol development; literature review • August 2015: KIT ethical approval • October 2015: Data collection instrument development and field testing; submission to Senegal’s ethical review board • January 2016: Field data collection • May 2016: Presentation of draft report • June 2016: Final report and brief 12/8/2015 24
  25. 25. Indicative Findings from Instrument Testing • Biggest benefits of PBF in terms of quality – Focus on important elements of quality – Financial support to purchase needed materials/equipment (specifically items on the checklist) – Motivation of personnel, especially community workers, to perform activities • Biggest constraints – Financial support doesn’t meet all needs – Inability to purchase more expensive equipment – Lack of sufficient technical supervision 12/8/2015 25
  26. 26. Indicative Findings from Instrument Testing • Most important activities to achieve quality – Ensuring availability of equipment – other programs matter – Avoiding drug stock-outs – Communication with the population • Emphasis on the quality checklist – Definitions of quality align with checklist indicators – Frequent mention of the checklist as a point of reference – Checklist criteria themselves are motivating, regardless of bonus payments 12/8/2015 26
  27. 27. Thank you!
  28. 28. EXTRA SLIDES
  29. 29. Quality Scores– (DS Kaffrine) 12/8/2015 29 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% General activities Management (financial, HR & medicines) Environmental hygiene and sterilization Infectious diseases (TB, Malaria, HIV) Maternal health Family planning Monitoring & evaluation/HIS Newborn care & vaccinations KAFFRINE 2012 2013 2014
  30. 30. Quality Scores– (DS Kolda) 12/8/2015 30 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% General activities Management (financial, HR & medicines) Environmental hygiene and sterilization Lab services Infectious diseases (TB, Malaria, HIV) Maternal health services Family planning Monitoring & evaluation/HIS Newborn care & vaccinations KOLDA 2012 2013 2014
  31. 31. Quality Scores – by district 12/8/2015 31 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% BIRKELANE KAFFRINE KOUNGHEUL MALEME HODDAR KOLDA MEDINA YORO FOULAH VELINGARA KAFFRINE KOLDA 2012 2013 2014
  32. 32. Quality Scores- by region 12/8/2015 32 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% KAFFRINE KOLDA 2012 2013 2014

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