How do performance-based financing programmes measure quality of care? A descriptive analysis of 68 quality checklists from 28 low- and middle-income countries

Abstract

This paper seeks to systematically describe the length and content of quality checklists used in performance-based financing programmes, their similarities and differences, and how checklists have evolved over time. We compiled a list of supply-side, health facility-based performance-based financing (PBF) programmes in low- and lower middle-income countries based on a document review. We then solicited PBF manuals and quality checklists from implementers and donors of these PBF mechanisms. We entered each indicator from each quality checklist into a database verbatim in English, and translated into English from French where appropriate, and categorized each indicator according to the Donabedian framework and an author-derived categorization. We extracted 8,490 quality indicators from 68 quality checklists across 32 PBF implementations in 28 countries. On average, checklists contained 125 indicators; within the same program, checklists tend to grow as they are updated. Using the Donabedian framework, 80% of indicators were structure-type, 19% process-type, and less than 1% outcome-type. The author-derived categorization showed that 57% of indicators relate to availability of resources, 24% to managing the facility and 17% assess knowledge and effort. There is a high degree of similarity in a narrow set of indicators used in checklists for common service types such as maternal, neonatal and child health. We conclude that performance-based financing offers an appealing approach to targeting specific quality shortfalls and advancing toward the Sustainable Development Goals of high quality coverage. Currently most indicators focus on structural issues and resource availability. There is scope to rationalize and evolve the quality checklists of these programs to help achieve national and global goals to improve quality of care.

High-quality health systems in the Sustainable Development Goals era: time for a revolution

“…Performance-based financing describes a set of approaches designed to improve health care by paying providers and facilities for the quantity and quality of care, though many programmes complement the financial incentives with direct improvement elements, such as training or supervision. 184,[309][310][311] Most performance-based financing programmes in LMICs incentivise primarily the quantity of services and, although they appear to increase utilisation of care and service volume, the effect of performance-based financing on quality is less clear. 184,310 Several impact evaluations are forthcoming from the World Bank's Health Results Innovation Trust Fund, a large funder of performance-based financing.…”

“…184,[309][310][311] Most performance-based financing programmes in LMICs incentivise primarily the quantity of services and, although they appear to increase utilisation of care and service volume, the effect of performance-based financing on quality is less clear. 184,310 Several impact evaluations are forthcoming from the World Bank's Health Results Innovation Trust Fund, a large funder of performance-based financing. 312,313 Overall, evidence to date suggests that performancebased financing has insufficient potential as a standalone strategy for system-wide quality improvement.…”

A Rapid Review of Available Evidence to Inform Indicators for Routine Monitoring and Evaluation of Respectful Maternity Care

“…[25][26][27] PBF, on the other hand, is generally a mechanism to measure and incentivize providers' and facilities' performance: facilities and providers earn incentives based on achievement of specific performance criteria. 21,28,29 For this review, we wanted to consider widely used approaches and platforms with potential to generate routine data for accountability on RMC in lower-resource settings. QI or assurance approaches have been used in LMICs for more than 30 years and are a major source of investment by major donors such as the United States Agency for International Development (USAID).…”

“…A recent review identified 32 programs in 28 LMICs, which collectively produced a total of 68 quality measurement tools. 28 Maternal and child health was often a focus and granting of rewards were based on measuring performance. Although the incentives were largely tied to aspects of structural quality versus process and outcome measures, there is potential to include RMC measures (now conceptualized as important aspects of quality) within these schemes.…”

Healthcare Digitalization and Pay-For-Performance Incentives in Smart Hospital Project Financing

“…Experimental P4P-based payment systems have led to rapid qualitative and quantitative improvements in access to healthcare [39]. P4P is a valuable tool for donors to guarantee transparency and accountability throughout the healthcare supply chain, which subsidizes local healthcare providers for achieving specific benchmarks.…”