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PBF and quality of care
The case of Burundi
Catherine Korachais*, Manassé Nimpagaritse, Kirrily de Polnay,
Bruno Meessen (...
BACKGROUND
2
• Free health care (reproductive and child health) since 2006:
• Assisted deliveries, antenatal care, family planning, etc...
• Growing literature on PBF
• Evidence on effects of PBF on health care utilisation in Burundi:
• No evidence on the effec...
• Assess the quality of care in Burundi:
– Practice of health workers
– Knowledge “ “
– Know-do gap “ “
• Explore the dete...
• We take the opportunity of an impact evaluation study
on PBF extended to Nutrition indicators
• 90 health centres take p...
7
90 health centres have been
selected (among ≈200 eligible)
• Baseline survey in health centres – end of 2014
– 90 health centres
– Content:
• Performance of malnutrition services - ...
Yes No
Is the child able to drink or breastfeed?
Does the child vomit everything?
Has the child had convulsions?
Does the ...
10
Data: vignettes
Yes No
Is the child able to drink or breastfeed? Yes
Does the child vomit everything? No
Has the child ...
• Do the HWs follow the IMCI guidelines?
• IMCI guidelines
– are in place in all heath centres in Burundi
– Aim: help HWs ...
For every child, IMCI guidelines recommend to:
• Ask the mother what the child’s problems are
• Check for
– general danger...
• Compute assessment questions and exams into scores
(counting items checked for), for each consultation and
for each vign...
FINDINGS
14
• 145 health workers
– from 1 to 6 consultations observed by health worker
(total 515 consultations)
– 3 vignettes adminis...
16
Characteristics of the health workers
17
Consultations Vignettes
History
All three danger signs asked for 0% 0%
No danger sign asked for 60% 48%
All four ‘main ...
Overall score
With
consultations
With
vignettes
Difference
Know do gap
mean 28.0 37.4 9.5
median 25.0 33.3 8.3
min 4.2 10....
19
Know-do gap
0
20406080
0 20 40 60 80
Vignette score
HW scores Fitted values
45 degree line
Consultation score Vignette score Know-do gap
Age (base 20)
30-39 1.907 2.823 0.645
(3.727) (4.313) (2.924)
40-49 0.671 -1...
• Poor level of health workers’ performance, both
through observations of consultations and vignettes
• Know-do gap exists...
• Low number of consultations per health worker,
Hawthorne effect
• Could go further with the score, with including:
– Qua...
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PbF and quality of care - the case of Burundi

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Catherine Korachais

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PbF and quality of care - the case of Burundi

  1. 1. PBF and quality of care The case of Burundi Catherine Korachais*, Manassé Nimpagaritse, Kirrily de Polnay, Bruno Meessen (ITM, Antwerp, Belgium) November 2015, RBF workshop, Dar es Salaam
  2. 2. BACKGROUND 2
  3. 3. • Free health care (reproductive and child health) since 2006: • Assisted deliveries, antenatal care, family planning, etc. • Immunisation, curative care for children under 5 years • Performance Based Financing (PBF) nationwide since 2010 • At health centre and hospital levels • PBF indicators coincide +/- free health care services (excl. Malnutrition) • Funding: half from national budget, half from external • In order to get more PBF subsides, health centres are encouraged to improve their services (related to these indicators) 3 Health care financing in Burundi
  4. 4. • Growing literature on PBF • Evidence on effects of PBF on health care utilisation in Burundi: • No evidence on the effects of PBF on health outcomes yet  That questions quality of care 4 Rationale
  5. 5. • Assess the quality of care in Burundi: – Practice of health workers – Knowledge “ “ – Know-do gap “ “ • Explore the determinants of quality of care • Reflect on the role of PBF related to quality of care 5 Objectives
  6. 6. • We take the opportunity of an impact evaluation study on PBF extended to Nutrition indicators • 90 health centres take part in this study 6 Data
  7. 7. 7 90 health centres have been selected (among ≈200 eligible)
  8. 8. • Baseline survey in health centres – end of 2014 – 90 health centres – Content: • Performance of malnutrition services - from clinical files: process and output • Organisational aspects of the health centre and of the nutrition services • Quality of services (patient-provider observations + exit-interviews) • Knowledge of health workers (clinical case studies) – Note: focus on paediatric curative consultations 8 Data
  9. 9. Yes No Is the child able to drink or breastfeed? Does the child vomit everything? Has the child had convulsions? Does the child have cough or difficulty breathing? If yes, for how long? Does the child have diarrhoea? If yes, for how long? If yes, is there blood in the stool? Does the child have fever? If yes, for how long? If yes, what is the frequency of fever episodes? Does the child have an ear problem? Check the child's immunization History Has the question been asked? If yes, what was the response? Yes No Is the child able to drink or breastfeed? P Does the child vomit everything? Has the child had convulsions? Does the child have cough or difficulty breathing? If yes, for how long? Does the child have diarrhoea? If yes, for how long? If yes, is there blood in the stool? Does the child have fever? If yes, for how long? If yes, what is the frequency of fever episodes? Does the child have an ear problem? Check the child's immunization History Has the question been asked? If yes, what was the response? Yes No Is the child able to drink or breastfeed? P No Does the child vomit everything? Has the child had convulsions? Does the child have cough or difficulty breathing? If yes, for how long? Does the child have diarrhoea? If yes, for how long? If yes, is there blood in the stool? Does the child have fever? If yes, for how long? If yes, what is the frequency of fever episodes? Does the child have an ear problem? Check the child's immunization History Has the question been asked? If yes, what was the response? Yes No Is the child able to drink or breastfeed? P No Does the child vomit everything? P Has the child had convulsions? P Does the child have cough or difficulty breathing? P Yes, he's coughing If yes, for how long? P Does the child have diarrhoea? P If yes, for how long? P If yes, is there blood in the stool? P Does the child have fever? P Yes If yes, for how long? P 2 days If yes, what is the frequency of fever episodes? P Does the child have an ear problem? P Check the child's immunization P Has the question been asked? If yes, what was the response?History 9 Data: patient provider observations Report on: - History taking - Exams - Diagnosis - Treatment - Communication X 6 / HC
  10. 10. 10 Data: vignettes Yes No Is the child able to drink or breastfeed? Yes Does the child vomit everything? No Has the child had convulsions? No Does the child have cough or difficulty breathing? Yes If yes, for how long? 5 days Does the child have diarrhoea? Not now, but it happened some times during the last two months If yes, for how long? Not now If yes, is there blood in the stool? No Does the child have fever? Yes If yes, for how long? Some days He is sometimes very hot History Has the question been asked? If yes, what was the response? What would you do in this case: A mother is coming to you, saying that her child is not going well 3 vignettes / HW 2 HWs/ HC
  11. 11. • Do the HWs follow the IMCI guidelines? • IMCI guidelines – are in place in all heath centres in Burundi – Aim: help HWs to quickly identify health problems of children below 5 years old and to manage them • Here we focus on the assessment part every HW should perform 11 Methodology
  12. 12. For every child, IMCI guidelines recommend to: • Ask the mother what the child’s problems are • Check for – general danger signs (questions) – main symptoms (questions) – vaccination status (questions) – vital signs (exam) – acute malnutrition status (exam) • Here we’ve left aside: – Particular assessment parts (e.g. items to check if diarrhoea) – Diagnosis and treatment parts; communication aspects 12 Methodology
  13. 13. • Compute assessment questions and exams into scores (counting items checked for), for each consultation and for each vignette – Overall score: 16 items • Practice of HW = average score of consultations • Knowledge of HW = average score of 3 vignettes • Know-do gap of HW = Knowledge - Practice 13 Methodology
  14. 14. FINDINGS 14
  15. 15. • 145 health workers – from 1 to 6 consultations observed by health worker (total 515 consultations) – 3 vignettes administered to each of them 15 Data Questionnaire Expected nb Collected nb Coverage Comment Management questionnaires 90 90 100% Consultation 90 x 6 = 540 515 95% Not enough consultations in 10 HCs Exit interview 90 x 6 = 540 512 95% Not enough consultations in 10 HCs And 3 mothers lost Vignettes 90 x 2 = 180 145 81% In 35 HCs: only one HW
  16. 16. 16 Characteristics of the health workers
  17. 17. 17 Consultations Vignettes History All three danger signs asked for 0% 0% No danger sign asked for 60% 48% All four ‘main symptoms’ asked for 4% 2% No ‘main symptoms’ asked for 3% 4% Vaccination status checked for 12% 16% Physical exam All three vital signs measured 0% 6% No vital sign measured 37% 21% All malnutrition status exams 3% 12% No malnutrition status exam 34% 17% Overall score (16 items; average in %) 28% 37% Diagnosis No correct diagnosis found out of 3 - 65% All 3 diagnoses correct - 2% N 145 145
  18. 18. Overall score With consultations With vignettes Difference Know do gap mean 28.0 37.4 9.5 median 25.0 33.3 8.3 min 4.2 10.4 -27.1 max 66.7 79.2 56.3 N 145 145 143 18 Know-do gap
  19. 19. 19 Know-do gap 0 20406080 0 20 40 60 80 Vignette score HW scores Fitted values 45 degree line
  20. 20. Consultation score Vignette score Know-do gap Age (base 20) 30-39 1.907 2.823 0.645 (3.727) (4.313) (2.924) 40-49 0.671 -1.335 -2.051 (5.509) (6.080) (4.467) 50+ -23.466*** -26.644** -2.929 (8.309) (10.355) (6.330) Gender (base : female) Male -6.555** 1.324 7.068** (3.279) (3.820) (2.920) Diploma (base : level A3) Level A2 0.892 -1.814 -1.178 (4.533) (5.493) (4.019) Level A1+ -8.101 -0.520 8.746 (10.087) (12.680) (5.945) Supervision (base : none in the six last months) Supervised -5.941* -8.212** -2.480 (3.206) (3.306) (2.948) Training PBF (base : none) Trained -0.345 -4.681 -4.123 (3.952) (4.628) (2.893) Training Nutrition (base : none) Trained 8.513*** 9.422** 1.484 (3.219) (3.658) (3.219) Observations 115 117 115 R-squared 0.216 0.171 0.144 Note: variables controlled for but not significant are not displayed (employer type, HC type, wage, population pressure) 20 Characteristics related to practice, knowledge & know-do gap
  21. 21. • Poor level of health workers’ performance, both through observations of consultations and vignettes • Know-do gap exists, though it seems rather low and less urgent than knowledge issues • Poor knowledge results call for more and better training and supervision of health workers • From these data, it’s impossible to assess PBF influence on quality of care – but strongly suggests that PBF alone (or without a real quality of care assessment module) is not enough to improve health outcomes 21 Summary of findings
  22. 22. • Low number of consultations per health worker, Hawthorne effect • Could go further with the score, with including: – Quality of management of cases of diarrhoea, fever, cough, ear problems – Treatment decisions according to diagnoses – Communication aspects • Other dimensions of quality of care 22 Limitations

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