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Learning from pilots : Effects of P4P on health worker motivation in Afghanistan
- 1. Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale1 | Learning from pilots: Effects of P4P on health worker motivation in Afghanistan Payment for Performance: a health systems perspective A workshop for scientists and practitioners Dar es Salaam – 24-26 November 2015 Elina M. Dale, PhD
- 2. Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale2 | Background MMR – 1575 per 100,000 live births, U5MR – 131 per 1,000 live births Need to improve access to basic health services Health workforce is one of the six health system building blocks RBF project goal in Afghanistan: "to impact MDGs 4 & 5 by improving coverage of MCH services" – Objectives: To increase key maternal & child health outputs, to improve quality of health services & to ensure higher patient satisfaction
- 3. Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale3 | Background Rationale for growing support for performance payments: – Principal-agent theory – Provider accountability, patients as clients – Evidence from countries, including Rwanda Theory on motivation is less unanimous on the positive effect of external rewards RBF evaluations so far focused on service delivery results Very few studies examine mechanisms
- 4. Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale4 | Results-based financing in health in Afghanistan: Study design 11 provinces, 442 facilities randomized to an intervention or a comparison arm: – Performance-based payments paid on a quarterly basis upon verification of results – Usual arrangement Prior to randomization facilities stratified by type & matched on average number of outpatient visits/month No blinding of the participants NGOs and facility management determine the within-facility distribution of payments
- 5. Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale5 | Data source: NHSPA 2012 - 2013 Part of the annual health facility survey implemented by JHSPH since 2004 in Afghanistan NHSPA 2012 – 2013 was implemented 23 months after the start of the RBF program Multi-stage stratified probability sampling: Health facility is a PSU, health worker is a secondary sampling unit 11 provinces, 256 facilities, 805 health workers
- 6. Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale6 | Methods Main analysis: Intention-to-treat Structural equation modeling using weighted least squares estimator for complex survey data for categorical outcomes
- 7. Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale7 | ITT results
- 8. Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale8 | Challenges in implementation that may explain these results Unmet expectations due to relatively small size of incentive payments in proportion to total salaries Weaknesses in HMIS and verification system causing delays in payments, which in turn undermined the perceived link between performance and payments No accompanying efforts to improve working conditions at facility level – Is motivation a key bottleneck to health system performance in this particular setting? If not, are performance payments (given all the implementation challenges and costs) the right solution? – If motivation is an issue, can it be addressed successfully without improvements in working conditions?
- 9. Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale9 | Challenges in implementation that may explain these results (cont) Autonomy given to NGOs and facilities was not accompanied with appropriate accountability mechanisms – No clear formulas for estimating performance of individual staff members and linking these to additional payments (e.g. “motivation contracts”) – Almost half of health workers from treatment facilities stated they did not receive performance payments – Within-facility distribution did not reflect the spirit of performance-based payments as in the majority of facilities additional funds earned through RBF were distributed in proportion to existing salaries Relationships to other health purchasing/provider payment systems and PFM mechanisms?
- 10. Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale10 | Thank you! Photo by Professor Gilbert Burnham
Notes de l'éditeur
- 9 December, 2015
- 9 December, 2015
- In 11 provinces of Afghanistan, 442 facilities were randomly assigned to an intervention or a comparison arm.
- No statistically significant changes were observed in health worker motivation in the intervention group as compared to the control group (p-value>0.05). Financial incentives in the form of performance-based payments did not seem to have an effect on health worker motivation factors.
- Approximately one year into the implementation of the RBF program, in the last quarter of 2011, there was a revision of payments for most of the indicators [69]. The payments per indicator had to be substantially increased because MOPH and implementing NGO monitoring activities showed that health workers were not satisfied with the rewards. it appears that prior to this revision, PBP as a proportion of base salary (not considering other mandatory allowances) ranged from 5.8% for doctors to 11% for assistant nurses (Table 4.9). However, it is worth emphasizing that this estimation is only in proportion to base salary. In addition to base salary, health workers in Afghanistan, particularly female health workers, are entitled to a number of allowances as described in the National Salary Policy [142]. Thus, male health workers serving in rural areas (which are most of the BPHS facilities) are automatically entitled to 50% increase to their base salary, while their female colleagues are entitled to 100% increase. The hardship allowance is increased further for areas that are considered to be rural (100% and 200% for males and females, respectively) and isolated (125% and 250% for males and females, respectively) [142, 162]. There are other allowances as well. The main premise of RBF: The causes of poor performance in the health system can be addressed at least partially by financial incentives. “If you pay more for something you will get more of it.” l
- Hierarchical budgetary systems basically rely on input-based accountability (did I spend my budget). So in moving to output-based payment, PBF, etc., a key policy issue is how we want to change the nature of accountability. So we are saying to the provider that you have more control over your internal resources, and in return, you need to … [what]. A big policy is to not only match changed autonomy with changed accountability, but to think a bit about what you want the providers to be accountable for. In turn, it means how to align accountability of providers with your overall policy objectives. No doubt there are some information requirements to go along with it as well. l Contracting relies on capitation, payments made directly to health-care providers for each individual enrolled with that provider, by various national and international NGOs for a list of services based on the BPHS. Currently the three major donors listed above support contracting for the BPHS. The World Bank covers eight provinces and six clusters (a cluster being a specified area within a province assigned to the NGO for delivery of services) through contracting with NGOs, as well as three provinces and one cluster through the Ministry of Public Health Strengthening Mechanism. USAID covers 13 provinces, of which seven are also covered by the World Bank. The European Commission covers 10 provinces (Fig. 1). The World Bank has a flexible incentive-led performance-based partnership agreement6 and channels its funds through the finance ministry to the public health ministry’s grants and contracts management unit, which is responsible for awarding and managing contracts to competing NGOs. USAID, which follows a cluster approach, previously contracted the process to an international NGO and now contracts through WHO. In contrast, the European Commission undertakes this work itself, contracting directly with NGOs. Contracting is based on lease contracts and NGOs are expected to achieve certain targets and to cover a given population with a package of basic health services, excluding those provided free of charge by agencies such as WHO, the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA). The criteria developed to select NGOs have been based on their previous knowledge of Afghanistan, experience in primary health-care programmes and capacity for service delivery. These are not classic contracts but “relational contracts”.7 In the case of Afghanistan, the obligations of the providers have been defined in general terms – these contracts cannot be easily challenged in the court of law in case of non-performance, and the only provision available to the purchaser is non-renewal of the contract. A team from Management Sciences for Health has estimated the cost of the BPHS based on a limited sample size of NGOs and facilities working for USAID.12 The reference cost used to negotiate the delivery of BPHS with contracted NGOs was US$ 4.5 for 2002. The cost varied among the different donors, ranging from US$ 3.8 to US$ 5.1 (Table 2, available at: http://www.who.int/bulletin/volumes/85/9/06-036939/en/index.html). Based on these figures, funding is allocated on a per-capita basis to NGOs that are obliged to implement the BPHS. In awarding new contracts, these figures have not so far been adjusted for inflation, which is estimated to be 10% per year.12 Claims have been made that a basic package of services could be provided for between US$ 3 and US$ 6 per capita per year in low-income countries.13 However, in the light of estimates of the cost of an essential package of health services at US$ 12 by the World Bank in 199314 and at US$ 34 by the WHO Commission on Macroeconomics and Health in 2001,15 concerns have been raised as to whether an essential package of services of adequate quality can be provided for US$ 4.5 per capita per year in Afghanistan, and about what impact such a package will have on health outcomes. y. For a PBF program to be successful, health facilities need to be given considerable flexibility. They need suffi cient funds and the freedom to manage resources in order to increase the quantity and quality of health services. Health facilities should have ample freedom for autonomous human resource management, hiring, and fi ring; procurement of supplies in a competitive and well- regulated market; and autonomous management of assets both fi xed and liquid. Health facilities should have the right to decide how to improve the quantity and quality of their services. Enhanced autonomy with regards to the use of public funds requires oversight, which necessitates the creation of a health facility committee. Apart from the standard fi nancial management tools used for accounting purposes, such as the income and expense registers and the quarterly income and expense statement that are auditable through the regular bureaucratic oversight mechanisms, public oversight is achieved through creating a health facility management committee (example Burundi). The indice tool forms part of the three PBF health facility tools: (a) the business plan, (b) the indice tool, and (c) the individual monthly health worker performance evaluation. Afghan National Salary Policy: In order to provide benefit for the seniority and also in order to encourage the staff for staying in rural area several options were proposed (formation of table for different of grade and steps, annual promotion in different steps etc) but as it could complicate the document the group agreed on: NGOs are expected to consider the seniority of the staff and based on the satisfactory performance the NGO will pay and annual increment of up to 5% of the basic salary (excluding hardship and other benefits) The Salary Policy will specify a”cap‘on the total benefit package that a health worker could receive. Actors could pay less than the specified cap, but not more. The total benefit package will be composed of: (i) the basic salary, (ii) an element for level of training and (iii) a rural hardship allowance commensurate with the level of rural hardship. . Cashin et al conclusion: The programmes are more successful when the incentive is integrated into and complements the underlying payment system. In most of the P4P programmes the power of the performance- related incentive payments tends to be modest relative to the incentives created by the underlying base payment system. In systems such as the US where providers receive revenue from multiple payers, the performance- related incentives are further weakened. Incentive payments seem to have the most potential to change provider behaviour where the P4P system is closely aligned and integrated with the underlying payment system particularly in a way that counteracts adverse incentives of the underlying payment system (e.g. Brazil OSS, Estonia QBS, Germany DMP, Maryland HAC, Turkey FM PBC, and UK QOF). The Germany DMP has demonstrated improved processes of care and better patient outcomes that are attributed not to a targeted financial incentive but to better alignment of the incentives of the underlying payment system with the evidence- based care processes for chronic conditions. The Maryland HAC programme carefully layered the incentive onto the underlying DRG payment system to counteract the incentive to reduce inputs per case and possibly skimp on quality. In the Brazil OSS programme, targeted financial incentives are integrated into the underlying payment system through the performance contracts to counteract the adverse incentives for low productivity under global budget payment. In the Australia PIP, on the other hand, higher volume practices have been disproportionately rewarded by PIP, which suggests that the P4P incentive payments have reinforced the adverse incentives of the underlying fee- for- service payment system..