In Tanzania, The Many Costs Of Pay-For-Performance Leave Open To Debate Whether The Strategy Is Cost-Effective

Borghi, Josephine; Little, Richard; Binyaruka, Peter; Patouillard, Edith; Kuwawenaruwa, August

doi:10.1377/hlthaff.2014.0608

Cited by 52 publications

(46 citation statements)

References 27 publications

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“…The significant reduction in outpatient visits at dispensaries in our study is consistent with concerns on the deterioration of non-targeted services reported elsewhere [ 35 , 36 ]. The result is also supported by findings from a costing study we conducted which estimated that health workers spent 17% of their time each month on data generation and verification activities related to P4P at primary level facilities including dispensaries, reducing available time to attend to patients [ 37 ]. Given these mixed findings, the net effect of P4P on service utilisation is unclear.…”

Section: Discussionsupporting

confidence: 55%

Effect of Paying for Performance on Utilisation, Quality, and User Costs of Health Services in Tanzania: A Controlled Before and After Study

et al. 2015

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BackgroundDespite widespread implementation across Africa, there is limited evidence of the effect of payment for performance (P4P) schemes in low income countries on the coverage of quality services and affordability, consistent with universal health coverage objectives. We examined the effect of a government P4P scheme on utilisation, quality, and user costs of health services in Tanzania.MethodsWe evaluated the effects of a P4P scheme on utilisation of all maternal and child immunization services targeted by the scheme, and non-targeted general outpatient service use. We also evaluated effects on patient satisfaction with care and clinical content of antenatal care, and user costs. The evaluation was done in 150 facilities across all 7 intervention districts and 4 comparison districts with two rounds of data collection over 13-months in January 2012 and February 2013. We sampled 3000 households of women who had delivered in the 12 months prior to interview; 1500 patients attending health facilities for targeted and non-targeted services at each round of data collection. Difference-in-difference regression analysis was employed.FindingsWe estimated a significant positive effect on two out of eight targeted indicators. There was an 8.2% (95% CI: 3.6% to 12.8%) increase in coverage of institutional deliveries among women in the intervention area, and a 10.3% (95% CI: 4.4% to 16.1%) increase in the provision of anti-malarials during pregnancy. Use of non-targeted services reduced at dispensaries by 57.5 visits per month among children under five (95% CI: -110.2 to -4.9) and by 90.8 visits per month for those aged over five (95% CI: -156.5 to -25.2). There was no evidence of an effect of P4P on patient experience of care for targeted services. There was a 0.05 (95% CI: 0.01 to 0.10) increase in the patient satisfaction score for non-targeted services. P4P was associated with a 5.0% reduction in those paying out of pocket for deliveries (95% CI: -9.3% to -0.7%) but there was no evidence of an effect on the average amount paid.ConclusionThis study adds to the very limited evidence on the effects of P4P at scale and highlights the potential risks of such schemes in relation to non-targeted service use. Further consideration of the design of P4P schemes is required to enhance progress towards universal health coverage, and close monitoring of effects on non-targeted services and user costs should be encouraged.

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Section: Discussionsupporting

confidence: 55%

Effect of Paying for Performance on Utilisation, Quality, and User Costs of Health Services in Tanzania: A Controlled Before and After Study

et al. 2015

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“…[314][315][316][317] Compared with alternative interventions, performance-based financing incurs unique costs for performance verification that can account for 10% to 15% of operating costs, including the cost of staff time. 318 There can also be unintended consequences of performance-based financing programmes, including reports that providers have threatened patients to report positive outcomes, but these programmes can also…”

Section: The Lancet Global Health Commissionmentioning

confidence: 99%

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

Kruk

Gage

Arsenault

et al. 2018

The Lancet Global Health

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The Lancet Global Health Commission and respecting all workers to deliver the best care possible. Fourth, governments and civil society should ignite demand for quality in the population to empower people to hold systems accountable and actively seek high-quality care. Additional targeted actions in areas such as health financing, management, district-level learning, and others can complement these efforts. What works in one setting might not work elsewhere, and improvement efforts should be adapted for local context and monitored. Funders should align their support with system-wide strategies rather than contribute to the proliferation of micro-level efforts. In this Commission, we assert that providing health services without guaranteeing a minimum level of quality is ineffective, wasteful, and unethical. Moving to a highquality health system-one that improves health and generates confidence and economic benefits-is primarily a political, not technical, decision. National governments need to invest in high-quality health systems for their own people and make such systems accountable to people through legislation, education about rights, regulation, transparency, and greater public participation. Countries will know that they are on the way towards a high-quality, accountable health system when health workers and policymakers choose to receive health care in their own public institutions. Components Quality impacts Better health Level and distribution of patient-reported outcomes: function, symptoms, pain, wellbeing, quality of life, and avoiding serious health-related suffering Confidence in system Satisfaction, recommendation, trust, and care uptake and retention Economic benefit Ability to work or attend school, economic growth, reduction in health system waste, and financial risk protection Processes of care Competent care and systems Evidence-based, effective care: systematic assessment, correct diagnosis, appropriate treatment, counselling, and referral; capable systems: safety, prevention and detection, continuity and integration, timely action, and population health management Positive user experience Respect: dignity, privacy, non-discrimination, autonomy, confidentiality, and clear communication; user focus: choice of provider, short wait times, patient voice and values, affordability, and ease of use Foundations Population Individuals, families, and communities as citizens, producers of better health outcomes, and system users: health needs, knowledge, health literacy, preferences, and cultural norms Governance Leadership: political commitment, change management; policies: regulations, standards, norms, and policies for the public and private sector, institutions for accountability, supportive behavioural architecture, and public health functions; financing: funding, fund pooling, insurance and purchasing, provider contracting and payment; learning and improvement: institutions for evaluation, measurement, and improvement, learning communities, and trustworthy data; intersectoral: roads, transport, wa...

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“…The result was a P4P pilot in 2011 that was implemented in the Pwani Region, whose evaluation has been completed [6, 27]. The P4P pilot in Tanzania received technical support from Clinton Health Access Initiative (CHAI) and financial support from Norway [26].…”

Section: Introductionmentioning

confidence: 99%

The inescapable question of fairness in Pay-for-performance bonus distribution: a qualitative study of health workers’ experiences in Tanzania

et al. 2016

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BackgroundDuring the last decade there has been a growing concern about the lack of results in the health sectors of many low income countries. Progress has been particularly slow in maternal- and child health. Prompted by the need to accelerate progress towards these health outcomes, pay-for- performance (P4P) schemes have been initiated in a number of countries. This paper explores the perceptions and experiences of health workers with P4P bonus distribution in the health system context of rural Tanzania.MethodsThis qualitative study was based on the P4P pilot in Pwani Region of Tanzania. The study took place in 11 health care facilities in Rufiji District. The study informants and participants were different cadres of health workers assigned to different outpatient and inpatient departments at the health facilities, and local administrators of the P4P bonus distribution. Thirty two in-depth interviews (IDIs) with administrators and health care workers, and six focus group discussions (FGDs with Reproductive and Child Health (RCH) staff, non-RCH staff and non-medical staff were conducted. Collected data was analyzed through qualitative content analysis.ResultsThe study found that the bonus distribution modality employed in the P4P programme was experienced as fundamentally unjust. The bonuses were calculated according to the centrality of the health worker position in meeting targeted indicators, drawn from the reproductive and child health (RCH) section. Both RCH staff and non-RCH perceived the P4P bonus as unfair. Non-RCH objected to getting less bonus than RCH staff, and RCH staff running the targeted RCH services, objected to not getting more P4P bonus. Non-RCH staff and health administrators suggested a flat-rate across board as the fairest way of distributing P4P bonuses. The perceived unfairness affected work motivation, undermined teamwork across departments and created tensions in the social relations at health facilities.ConclusionOur results suggest that the experience of unfairness in the way bonuses are distributed and administered at the health facility level undermines the legitimacy of the P4P scheme. More importantly, long term tensions and conflicts at the workplace may impact negatively on the quality of care which P4P was intended to improve. We argue that fairness is a critical factor to the success of a P4P scheme and that particular attention should be paid to aspects of workplace justice in the design of P4P bonus structures.

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In Tanzania, The Many Costs Of Pay-For-Performance Leave Open To Debate Whether The Strategy Is Cost-Effective

Cited by 52 publications

References 27 publications

Effect of Paying for Performance on Utilisation, Quality, and User Costs of Health Services in Tanzania: A Controlled Before and After Study

Effect of Paying for Performance on Utilisation, Quality, and User Costs of Health Services in Tanzania: A Controlled Before and After Study

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

The inescapable question of fairness in Pay-for-performance bonus distribution: a qualitative study of health workers’ experiences in Tanzania

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