Transcript Impact Evaluation of Performance
A collaboration between the Rwanda Ministry of Health, CNLS, SPH, INSP Mexico, UC Berkeley and the World Bank
Paulin Basinga
Rwanda School of Public Health
Christel Vermeersch
World Bank
Our team…
Research Team Paulin Basinga, National University of Rwanda Paul Gertler, UC Berkeley Jennifer Sturdy, World Bank and UC Berkeley Christel Vermeersch, World Bank Policy Counterpart Team Agnes Binagwaho, Rwanda MOH and CNLS Louis Rusa, Rwanda MOH Claude Sekabaraga, Rwanda MOH Agnes Soucat, World Bank
P4P for Health in Rwanda
Objectives Focus on maternal and child health (MDGs 4 & 5) Increase quantity and quality of health services provided Increase health worker motivation What?
Financial incentives to providers t For more quantity And more quality How?
Contracts between g overnment & health facilities When?
Piloted in 2001-2005, full scale from 2006 5
Table 1: Output Indicators (U’s) and Unit Payments for PBF Formula OUTPUT INDICATORS Visit Indicators: Number of …
5 6 7 1 2 3 4 curative care visits first prenatal care visits women who completed 4 prenatal care visits first time family planning visits (new contraceptive users) contraceptive resupply visits deliveries in the facility child (0 - 59 months) preventive care visits
Content of care indicators: Number of …
8 9 10 11 women who received tetanus vaccine during prenatal care women who received malaria prophylaxis during prenatal care at risk pregnancies referred to hospital for delivery emergency transfers to hospital for obstetric care 12 13 14 children who completed vaccinations (child preventive care) malnourished children referred for treatment other emergency referrals
Amount paid per unit (US$)
0.18 0.09 0.37 1.83 0.18 4.59 0.18 0.46 0.46 1.83 4.59 0.92 1.83 1.83
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Evaluation Questions Did P4P improve… … the quality and quantity of maternal and child health services?
… the health of the population?
Conceptual framework for quality
What They Do (Quality) Production Possibility Frontier Productivity Gap Conditional on Ability Actual Performance What they know (Ability/Technology)
Identifying the impact of P4P
When we see a change in outcome, how do we know it is caused by P4P? And not by something else Evaluate the impact = identifying a comparison group Equivalent to the treated group in all aspects Except that they receive the treatment Gold standard: randomized evaluation 11
Evaluation Design
Phased roll-out at district level Identified districts without P4P in 2005 Group districts into “similar pairs” based on population density, location & livelihoods Randomly assign one to treatment and other to control Phase I: 12 districts, started 2006 Phase II: 7 districts, started 2008 Unit of observation is health facility 12
Rollout of P4P 2006 – 2008
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A few challenges
The decentralization “surprise”
A few new districts had some facilities with P4P– must be treatment Exposure time to the “treatment” Is it more money? Or more incentives?
Other interventions & time trends Coordination with multiple donors 14
Data
Independent data Facilities level Utilization (quantity) Structural quality Knowledge (vignettes) Process quality (patient exit surveys) Household level Utilization Process quality Health outcomes 15
Sample
Out of 30 districts 12 Phase I (treatment) 7 Phase II (comparison)
165 health facilities
All rural health centers located in 19 districts 2156 households in catchment areas Power calculations based on expected treatment effect on prenatal care visits, institutional delivery Panel data: 2006 and 2008 16
Econometric model
Basic difference-in-differences model specified as a two-way fixed effect cross-sectional time-series regression models.
Y ijt
j
2008
PBF jt
k
k X kit
ijt
where : •
Y ijt
is the outcome of interest for individual i living in facility j’s catchment • area in year t; • • • • •
γ 2008
PBF j,2008
X ijt j itk
= 1 if facility j was paid by PBF in 2008 and 0 if otherwise; are facility fixed effects; =1 if the year is 2008 and 0 if 2006; are time varying individual characteristics; is a zero mean error term.
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Evaluation design challenges
Organizational Managing expectations The John Henry effect in practice Building capacity Time & effort Technical Small sample size Reconciling provider and client data 18
Baseline, health facilities
Observations
Treatment
75
Control
70
Difference p value* Expenditures and Budget Shares
Log Total Expenditures (2006) Log Total Expenditures (2008) Personnel Budget Share Medical Supplies Budget Share Non-medical Budget Share
Staffing
Medical Doctors Nurses Other Clinical Staff Non-clinical Staff
Structural Quality (Baseline 2006)
Curative Care Delivery Prenatal Care Immunization Laboratory 15.81 16.91 0.46 0.22 0.32 0.05 6.31 4.13 5.25 0.80 0.78 0.96 0.94 0.49 (1.04) (0.71) (0.23) (0.19) (0.25) (0.23) (6.90) (3.09) (3.56) (0.07) (0.11) (0.15) (0.17) (0.32) 15.61 16.99 0.49 0.20 0.30 0.05 5.48 4.47 5.33 0.81 0.79 0.97 0.94 0.43 (1.01) (1.08) (0.26) (0.19) (0.22) (0.27) (3.30) (4.05) (5.09) (0.07) (0.10) (0.11) (0.15) (0.32) 0.200 -0.083 -0.031 0.013 0.018 0.003 0.826 -0.335 -0.076 -0.01 0.00 -0.01 0.00 0.06 All of the data, except Log Expenditures 2008, are measured at baseline prior to the intervention. Data are n (%) or mean (SD). Sample size varies slightly according to characteristic measured *P-values are for cluster-adjusted t-test (continuous variables). 0.418 0.568 0.555 0.705 0.726 0.940 0.409 0.554 0.901 0.575 0.840 0.285 0.897 0.402 19
Baseline, utilization of maternal health services
Treatment Control Difference p-value* Maternal care utilization
Any prenatal care (=1) 4 or more prenatal care visits Delivery in health facility (=1) 0.95
0.18
2.76
0.35
(0.21) (0.38) (0.84) (0.48) 0.96
0.11
2.62
0.36
(0.20) (0.31) (0.80) (0.48) -0.01
0.07
0.14
-0.01
Data are n (%) or mean (SD). Sample size varies slightly according to characteristic measured *P-values are for cluster-adjusted t-test (continuous variables) or chi-squared (dichotomous variables) tests of independence. 0.773
0.036
0.180
0.801
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Baseline, women 15-49 with birth in last 24 months
Treatment
620
Control
670
Difference p-value*
Observations
Maternal characteristics
Age Primary education or more (=1) Currently married/union (=1) Partner present (=1) Number of pregnancies (Parity) Number of living children Health insurance (=1) 30.89
0.42
0.94
0.98
4.32
3.39
0.55
(7.05) (0.03) (0.23) (0.14) (2.46) (1.93) (0.50) 31.22
0.35
0.91
0.97
4.33
3.51
0.52
(6.85) (0.04) (0.29) (0.17) (2.43) (2.62) (0.50) -0.33
-0.01
0.04
0.01
-0.01
-0.12
0.04
0.594
0.889
0.214
0.325
0.969
0.490
0.591
Household characteristics
Number of household members Ownership of land (=1) Poverty inderx (Value of animals, durable
Poverty index quartile 1 Poverty index quartile 2 Poverty index quartile 3 Poverty index quartile 4
Distance : household - facility (in km) 5.15
0.93
0.22
0.25
0.27
0.25
3.24
(1.70) (0.25) (0.42) (0.43) (0.45) (0.43) (2.00) 5.40
0.87
0.22
0.25
0.28
0.24
3.40
(1.94) (0.33) (0.42) (0.43) (0.45) (0.43) (2.01) -0.25
0.06
0.00
0.00
-0.01
0.01
1.58
0.145
0.126
0.994
0.885
0.885
0.772
0.667
Data are n (%) or mean (SD). Sample size varies slightly according to characteristic measured *P-values are for cluster-adjusted t-test (continuous variables) or chi-squared (dichotomous variables) tests of independence. 21
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Impact on structure quality
Impact of PBF N Treatment 2008 (=1) SD Time Trend 2008 (=1) SD
Availability of vaccines Prenatal care service 155 155 0.703** (0.355) 0.062 (0.426) -0.514*** -0.659*** (0.122) (0.100) Delivery service 155 0.239 (0.286) -0.484*** (0.083) 23
Kernel Non parametric regression practice-competency at baseline .3
.4
Competence .5
.6
Control facilities Treatment facilities .7
.8
Kernel Non parametric regression practice-competency at follow up .3
.4
Competence .5
.6
Control facilities Treatment facilities .7
Impact on quality of prenatal care
Impact of PBF Time Trend N Treatment 2008 (=1) SD 2008 (=1) SD Total Prenatal Quality Score (standardized score) Tetanus vaccine during prenatal visit (=1)
3683 2810 0.157*** (0.048) 0.054** (0.023) 0.090*** 0.032
(0.032) (0.028)
Productivity ratio
3757 0.072*** (0.017) 0.036*** (0.012)
Treatment * 2008 * Competency > 75% (=1)
3739 0.088*** (0.019) NA NA 26
Impact on quality of prenatal care
0.20
0.15
0.10
0.05
0.00
-0.05
-0.10
-0.15
-0.10
-0.13
Baseline (2006)
Control facilities
0.15
0
15 % Standard deviation increase due to PBF
Follow up (2008)
Treatment (PBF facilities)
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Impact on use of prenatal care
Impact of PBF Time Trend N
Number of prenatal visits received 2223
Treatment 2008 (=1) SD
-0.028 (0.066)
2008 (=1)
0.237***
SD
(0.056) Likelihood of first prenatal visit in first trimester 2223 Made 4 or more prenatal care visits 2223 0.020 (0.036) 0.009 (0.039) 0.163*** 0.121*** (0.029) (0.023) 28
Impact on use of maternal services
Impact of PBF Time Trend N
Institutional delivery (=1) 2108 Delivery attended by Qualified Provider (=1) 2274 Use of any modern contraceptive method (=1) 3121
Treatment 2008 (=1) SD
0.077** (0.034) 0.083** (0.035) -0.017 (0.023)
2008 (=1)
0.134*** 0.195*** 0.245***
SD
(0.023) (0.028) (0.033) 29
Impact on institutional delivery
60.0
55.6
7.3 % increase due to PBF
50.0
49.7
40.0
30.0
36.3
34.9
Baseline (2006) Control facilities Follow up (2008) Treatment (PBF facilities)
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What our results tell us
You get what you pay for ! Need to get prices “right” Returns to effort important Bigger effects in things more in provider’s control Patient or community health workers for prenatal care/Immunization Provide incentives directly to pregnant women? (conditional cash transfer program).
Financial incentive to community health workers Low quality of care : additional training coupled with P4P Evaluation feedback useful 31
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