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Performance-Based Financing and Quality of Health Services in LIC György Fritsche, Sr Health Specialist HNP-The World Bank April 7, 2011 Outline • The Issue – Why? – 6 pictures • What is Performance-Based Financing? – Purchasing Quantity – Purchasing Quality • Some Results and Some Footnotes – Some Results – Some Footnotes On a personal note.. Waste disposal Polypharmacy & Irrational Prescribing.. Management… Treatment Guidelines… Inpatient care 1… What is PBF? • “Performance-Based Financing is a health systems approach with an orientation on results defined as quantity and quality of service outputs. This approach entails making health facilities autonomous agencies that work for the benefit of health related goals and their staff. It is also characterized by multiple performance frameworks for the regulatory functions, the performance purchasing agency and community empowerment. Performance-Based Financing applies market forces but seeks to correct market failures to attain health gains. PBF at the same time aims at cost-containment and a sustainable mix of revenues from cost-recovery, government and international contributions. PBF is a flexible approach that continuously seeks to improve through empirical research and rigorous impact evaluations which lead to best practices.” FRITSCHE, G., SOETERS, S., Meessen, B., NDIZEYE, C (2011). ‘PBF toolkit “Checklist for Implementers”, The World Bank, Washington DC (under development) Quantity and Quality are counted… Separation of Functions… Rwanda PBF impact: Increase in Deliveries but not in ANC4… Rwanda PBF Impact: Large increases in frequency of U5 preventive visits in PBF facilities… Rwanda PBF Impact: providers did more of what they knew & the more they knew the better they did… Impact on quality of services measured through the Quantified Quality Checklist 2…. HIV services Footnote 1: Ex ante control DH for HC quality: too close for comfort? …. Relative difference of quality evaluation Byumba Gitwe Kabgayi Kanombe Kirehe Munini 0% -10% -20% ALL Accouchement -30% CPC -40% Finance -50% -60% -70% -80% org. generale Pharmacie Footnote 2: Conclusions on the PBF counter-verifications…. • Quality as assessed by DH-evaluators consistently higher compared to independent unit : – conflict of interest? – No real PBF-evaluation? – Complacency? – Miscomprehension of indicators? References for PBF • • • • • • • • • • MEESSEN, B., KASHALA, J.-P. & MUSANGO, L. (2007) Output-based payment to boost staff productivity in public health centers: contracting in Kabutare district, Rwanda. Bulletin of the World Health Organization, 85, 108-115. MEESSEN, B., MUSANGO, L., KASHALA, J.-P. I. & LEMLIN, J. (2006) Reviewing institutions of rural health centres: the Performance Initiative in Butare, Rwanda. TMIH, 11, 1303-1317. MEESSEN, B., SOUCAT, A. & SEKABARAGA, C. (2011) Performance-based financing: just a donor fad or a catalyst towards comprehensive health care reform? Bulletin of the World Health Organization (in press). SOETERS, R. (2010) PBF in Action: Theory and Instruments. The Hague. SOETERS, R. & GRIFFITHS, F. (2003) Improving government health services through contract management: a case from Cambodia. Health Policy and Planning, 18, 74-83. SOETERS, R., HABINEZA, C. & PEERENBOOM, P. B. (2006) Performance-based financing and changing the district health system: experience from Rwanda. Bulletin of the World Health Organization, 84. SOETERS, R., KIMUNUKA, C., PEERENBOOM, P. & MUSHAGULUSA, P. (2011) Performance Based Health Financing Experiment Improves Care in a Failed State. Health Affairs (in press). BASINGA, P., GERTLER, P., BINAGWAHO, A., SOUCAT, A., STURDY, J. & VERMEERSCH, C. (2010) Paying Primary Health Care Centers for Performance in Rwanda. Policy Research Working Paper no 5190. Washington DC, The World Bank. MUSGROVE, P. (2010) Financial and Other Rewards For Good Performance or Results: A Guided Tour of Concepts and Terms and a Short Glossary. Washington DC. FRITSCHE, G., SOETERS, S., Meessen, B., NDIZEYE, C (2011). ‘PBF toolkit “Checklist for Implementers”, The World Bank, Washington DC (under development)