Impact of performance-based financing on primary health care services in Haiti

Abstract

To strengthen Haiti's primary health care (PHC) system, the country first piloted performance-based financing (PBF) in 1999 and subsequently expanded the approach to most internationally funded non-government organizations. PBF complements support (training and technical assistance). This study evaluates (a) the separate impact of PBF and international support on PHC's service delivery; (b) the combined impact of PBF and technical assistance on PHC's service delivery; and (c) the costs of PBF implementation in Haiti. To minimize the risk of facilities neglecting potential non-incentivized services, the incentivized indicators were randomly chosen at the end of each year. We obtained quantities of key services from four departments for 217 health centres (15 with PBF and 202 without) from 2008 through 2010, computed quarterly growth rates and analysed the results using a difference-in-differences approach by comparing the growth of incentivized and non-incentivized services between PBF and non-PBF facilities. To interpret the statistical analyses, we also interviewed staff in four facilities. Whereas international support added 39% to base costs of PHC, incentive payments added only 6%. Support alone increased the quantities of PHC services over 3 years by 35% (2.7%/quarter). However, support plus incentives increased these amounts by 87% over 3 years (5.7%/quarter) compared with facilities with neither input. Incentives alone was associated with a net 39% increase over this period, and more than doubled the growth of services (P < 0.05). Interview findings found no adverse impacts and, in fact, indicated beneficial impacts on quality. Incentives proved to be a relatively inexpensive, well accepted and very effective complement to support, suggesting that a small amount of money, strategically used, can substantially improve PHC. Haiti's experience, after more than a decade of use, indicates that incentives are an effective tool to strengthen PHC.

Improving primary health care facility performance in Ghana: efficiency analysis and fiscal space implications

“…Indeed, the findings of the study show that health facilities that are on the PBF scheme have higher efficiency score relative to facilities not on the scheme. Zeng et al [26] also provided evidence to confirm the relevance of PBF in health service delivery at the primary level. They found that in Haiti, even modest incentives from PBF schemes were associated with notable growth rates in service delivery.…”

How are pay-for-performance schemes in healthcare designed in low- and middle-income countries? Typology and systematic literature review

“…Schemes rewarding multiple outcomes differed dramatically in their complexity. Some schemes rewarded just a handful of indicators, for instance a P4P scheme in Haut-Katang in the DRC rewarded seven indicators [45] or a P4P scheme in Haiti rewarded 14 indicators [46]. However, others are extremely complex, a good example is Brazil's national P4P scheme (called PMAQ -National Program for Improving Primary Care Access and Quality), which rewarded over 600 different indicators [47].…”

“…Information on whose performance was measured was provided for all identified P4P schemes and information on who ultimately received the payment was available for 38 out of 41 schemes. Most identified P4P schemes (76%) measured the performance of health institutions such as primary healthcare facilities [46] or hospitals [48]. However, 86% of P4P schemes in LMICs paid financial bonuses to individual providers.…”

“…Most identified P4P schemes were implemented by nongovernmental or international organisation (58%) or by regional or national governments (24%). The majority of P4P schemes in LMICs (68%) were implemented with some form of external technical assistance by international NGOs or international organisationsas was the case in Haiti [46] Afghanistan [10] and Bangladesh [59]. All included schemes implemented in low-income settings were implemented with some form of external technical assistance, compared to 50% of schemes in middle-income settings.…”

A preliminary assessment of financial stability, efficiency, health systems and health outcomes using performance-based contracts in Belize

“…A randomised evaluation of P4P in Rwanda demonstrated a significant increase in maternal and child health services compared to facilities that did not receive performance incentives (Basinga et al, 2011). Another study in Haiti associated performance-based financing with significant improvement in the quantities of primary health care services for infants and pregnant women (Zeng, Cros, Wright, Shepard, 2012). …”