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Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale1 |
Learning from pilots: Effects of P4P
on health...
Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale2 |
Background
 MMR – 1575 per 100,000 live birth...
Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale3 |
Background
 Rationale for growing support for...
Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale4 |
Results-based financing in health in
Afghanist...
Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale5 |
Data source: NHSPA 2012 - 2013
 Part of the a...
Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale6 |
Methods
Main analysis: Intention-to-treat
Stru...
Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale7 |
ITT results
Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale8 |
Challenges in implementation that may
explain ...
Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale9 |
Challenges in implementation that may
explain ...
Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale10 |
Thank you!
Photo by Professor Gilbert Burnham
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Learning from pilots : Effects of P4P on health worker motivation in Afghanistan

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Elina Dale

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Learning from pilots : Effects of P4P on health worker motivation in Afghanistan

  1. 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. 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. 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. 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. 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. 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. 7. Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale7 | ITT results
  8. 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. 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. 10. Effects of P4P on health worker motivation in Afghanistan| Elina M. Dale10 | Thank you! Photo by Professor Gilbert Burnham

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