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the effect of P4P on the knowledge - practice gap in Tanzania

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Josephine Borghi

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the effect of P4P on the knowledge - practice gap in Tanzania

  1. 1. Effects of Payment for Performance on Knowledge, Practice and the Know-Do Gap Evidence from Pwani, Tanzania Josephine Borghi 24th November RBF – a health systems perspective. White Sands Hotel, Dar es Salaam.
  2. 2. Rationale • P4P is expected to improve quality and service coverage through changed health worker behaviour • Improvements in health worker knowledge and practice is necessary for optimal health gain • Knowledge may increase through substitution of health workers; greater investment in training • Practice (or application of knowledge) is likely to increase through a desire to meet targets, and improved resource availability • In Rwanda found limited effect on knowledge and improvements in practice, especially among those with higher knowledge levels. • Aim: examine P4P effects on knowledge, practice and the gap in Tanzania using data from our evaluation in Pwani
  3. 3. P4P in Tanzania Aim: A pilot introduced in 2011 focusing on MCH service coverage to inform a national programme Location: Pwani region of Tanzania Implementers: MOHSW and CHAI Funder: Government of Norway
  4. 4. Scheme Design Facility level targets: – ANC: IPT2; % HIV+ women on ART – Institutional delivery rate – % of newborns with OPV0 in first 2 weeks – % infants with Penta 3; measles vaccine – % of PNC visit w/n 7 days – CYP – HMIS reports correctly filled and submitted on time + use of partograms District – regional level targets: – % of maternal/perinatal deaths audited on time – % of facilities with stock outs
  5. 5. Study Design • Design: Controlled before and after study design – 7 intervention districts – 4 neighbouring control districts – Comparable poverty, literacy, rate of institutional deliveries, IMR, pop. per health facility, no. of children < 1 yr • Timing: -Baseline in January-February 2012 -Endline in March-April 2013 (13 months)
  6. 6. 7 P4P districts 4 districts with no P4P 150 health facilities, 75 in each arm incl. 6 hospitals 16 health centres 53 dispensaries 1 facility survey at each facility 20 interviews with women who delivered in past 12 months, from the catchment area of each facility Only include facilities eligible for first cycle payment 1-2 health workers at each facility
  7. 7. Measurement: Knowledge • Used a clinical “vignette”: a hypothetical patient case, in this case, a woman attending her first antenatal visit. • Derived from the World Bank Impact Evaluation Toolkit • Presented to health workers who regularly provide ANC • 45 items from the antenatal clinical guidelines were covered in the vignettes, with items corresponding to four dimensions: – patient medical history – physical examinations – laboratory investigations – drugs prescriptions. • Measure scores for each dimension and in total: number of items mentioned by the total number of items.
  8. 8. Measurement: Practice • Procedures performed by the provider on patients (adherence to protocol). • Household interviews with women attending ANC during their current or last pregnancy living within the catchment area of facilities where health workers were surveyed • A total of 18 items regarding ANC services, 11 match the 45 items in the health workers survey • Dimensions of care: – physical examinations – laboratory investigations – drugs prescription. • We constructed an additional dimension relating to client counselling and educational services.
  9. 9. Measurement: Gap • The knowledge–practice gap measures provider efficiency to translate knowledge into actual ANC practice. • Defined as the difference between the knowledge and practice share of clinical guidelines for an ANC visit. • Women linked to a given facility by its catchment area are matched to the health workers’ responses for that same facility. • Take average value for knowledge measure at facility level where more than one health worker was surveyed per facility. • Measured for 11 items across: – physical examinations – laboratory investigations – drugs prescribed.
  10. 10. Analysis • Used a difference-in-difference identification strategy: • 𝐾ℎ𝑗𝑡 = 𝛽0 + 𝛽1(𝑃4𝑃𝑗 × 𝛿𝑡) + 𝛽2 𝛿𝑡 + 𝛽3 𝑍ℎ𝑗𝑡 + 𝛾𝑗 + 𝜀ℎ𝑗𝑡 • 𝑌𝑖𝑗𝑡 = 𝛽0 + 𝛽1(𝑃4𝑃𝑗 × 𝛿𝑡) + 𝛽2 𝛿𝑡 + 𝛽3 𝑍𝑗𝑡 + 𝛽4 𝑋𝑖𝑗𝑡 + 𝛾𝑗 + 𝜀𝑖𝑗𝑡 • 𝐾ℎ𝑗𝑡 knowlegde share of ANC guidelines by provider h at health facility j in period t • 𝑌𝑖𝑗𝑡 is the practice share or the gap • 𝑃4𝑃𝑗 is a dummy variable taking the value of 0 for comparison facilities and 1 for intervention facilities; • 𝛿𝑡 is a year fixed effects dummy taking the value of 0 at baseline and 1 at endline; • 𝑍ℎ𝑗𝑡 health worker-level characteristics expected to drive programme outcomes • 𝑋𝑖𝑗𝑡 are household level characteristics expected to drive programme outcomes • 𝛾𝑗 is a facility fixed effects to control for facility-level time invariant characteristics; and 𝜀ℎ𝑗𝑡 is a random error term • Assumption: pre-trends in outcomes are parallel
  11. 11. Impact on ANC Knowledge Variables Baseline Impact P4P Control Diff % effect of P4P Knowledge shares for each dimension Medical history taking (% of items known) 26 items 20.2 34.1 -13.9*** 12.5*** Physical examinations (%) 10 items 25.5 42.7 -17.2*** 11.9*** Lab investigations (%) 7 items 26.7 48.4 -21.6*** 18.5*** Drug prescriptions (%) 2 items 63.8 87.1 -23.3*** 16.2*** Total items known (%) 45 items 24.3 40.6 -16.3*** 13.4*** Total items known – gap (%) 11 items 42.0 64.6 -22.7*** 17.6***
  12. 12. Impact on ANC Practice Variables Baseline Impact P4P Control Diff % effect of P4P Practice shares for each dimension Client Counselling (% of items done) 7 items 78.6 71.8 6.8*** -3.2* Physical examinations (%) 6 items 89.4 87.7 1.7 0.2 Lab investigations (%) 3 items 86.8 83.2 3.6* 2.2 Drug prescriptions (%) 2 items 71.4 73.6 -2.2 7.1** Total items done (%) 18 items 82.6 79.1 3.5*** 0.0 Total items done – gap (%) 11 items 85.3 83.9 1.5 2.0*
  13. 13. Impact on ANC Know-Do Gap Variables Baseline Impact P4P Control Diff % effect of P4P Gap shares for each dimension Physical examinations (%) 6 items -54.4 -34.7 -19.7*** 9.2* Lab investigations (%) 3 items -43.1 -6 -28.0*** 18.6*** Drug prescriptions (%) 2 items -2.5 14.9 -17.5*** 2.8 Total items (%) 11 items -39.1 -17.9 -21.2*** 10.1*
  14. 14. Conclusions • P4P significantly improved health worker knowledge across all dimensions • Plausible? • District managers shifted efficient workers to help those struggling to meet targets. • Opportunities to upgrade skills with training increased as a result of P4P from health worker survey. • Knowledge indication of ‘intended behaviour’ – may be more responsive to P4P in the short term than practice • P4P improves practice in relation to incentivised components of care: drug prescriptions but no evidence of other improvements in adherence to care guidelines • As knowledge increases and practice generally doesn’t – the inefficiency gap increases
  15. 15. Limitations • Imbalance in baseline knowledge between intervention and control • Unable to assess whether trends in knowledge and practice were parallel prior to P4P; trends in ANC coverage were • Gap analysis: – Tools not originally intended to pursue this gap analysis – and only a limited number of items could be compared in this way • Consider the one-two health workers interviewed as representative of ‘practice’ at a given facility which may not be the case • Assume households went to their nearest facility for ANC • Concern that practice found to exceed knowledge at baseline (negative gap)
  16. 16. Acknowledgements • Josephine Borghi – LSHTM • Paola Vargas – LSHTM/OPM • Peter Binyaruka - LSHTM • Powell-Jackson T - LSHTM • Patouillard E - LSHTM • Torsvik G – CMI • Mayumana I – IHI • Masuma Mamdani - IHI • Lange S - CMI • Maestad O - CMI

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