Transcript Performance-based financing

Performance-based financing:
Shush, it is about reform!
CERDI, 17/12/2009
Agnès Soucat (World Bank), Bruno Meessen
(Institute of Tropical Medicine, Antwerp)
Outline
• PBF under the fire: a review of the
criticisms.
• It is about reform : PBF as a potential
game changer for health systems in low
income countries.
Several drives for critiques against
PBF (1): the perspective
•
Personal fear, suspicion, ( hostility?) towards payment against
performance / economists: very present among public health doctors
(often outliers in terms of values and professional ethos, even within the
medical profession).
•
Philosophical / normative view: ‘fair pay for fair work’, output-based
payment would be an unfair method to pay people. Legitimate as any
normative view, as long as:
– (1) one does not deny the fact (e.g. the situation of all self-employed
around the world; fees-for-services in the health sector;most unions are
not against bonus);
– (2) culturally tainted: different individuals / societies may have a different
view than Western people, experts or unions.
•
Vested interest: health staff: « pay us a high salary and trust us »; inputbased financing can be comfortable also for the aid sector / the health
authorities.
•
From the desk / from the field.
Absenteeism plagues primary
schools and health facilities
50
40
30
20
10
0
Bangladesh
Ecuador
India
Indonesia
Primary schools
Papua New
Guinea
Peru
Primary health facilities
Zambia
Uganda
Several drives for critiques against
PBF (2): the evidence
• Lack of supportive evidence in LIC: but constrained by
the lack of experiences in LIC. Obviously, evidence must
start somewhere.
• « Evidence in HIC is not that supportive »: a major
mistake in terms of external validity of findings:
institutional arrangements and incentive structure are so
different.
• Difficulty to attribute impact: a major effort is made by
some actors in terms of impact evaluation.
• Interpretation of evidence: we feel that while many
good achievements are reported, researchers
stress/speculate on the negative effects.
Several drives for critiques against
PBF (3): the dynamic
• Concern about over-enthusiasm; PBF as the new
hype; the new mode in international aid. An issue and a
risk indeed, and the World Bank is contributing to the
surge of enthusiasm.
• Misunderstanding on the objective and rationale:
PBF seen as an isolated strategy (our focus).
• Misunderstanding of what is going on: opinions
based on what is published; some PBF authors are too
narrow on their explanation.
• Misinterpretation of what is said: PBF as the only
cause of improvement of MDGs in Rwanda; PBF as a
magic bullet; PBF as a strategy without side effects.
Several drives for critiques against
PBF (4): the theory
• Providers in multi-tasking set-up: they will deliver
what is remunerated; overlook what is not. The very logic
of PBF; the problem is that PBF remunerates only what
is measurable; are we measuring what really matters?
Not everything that matters can be measured. The main
limit of PBF? How do health professional make decisions
when paid based on inputs: rationing ? Cientelism?
Skirting?
• Gaming (cheating): an issue for any monitor, but
indeed the risk is higher when a reward is linked to the
measured performance, (moral hazard)
Several drives for critiques against
PBF (5): the experiences
•
Mistakes in the design: wrong indicators (e.g. which do not measure much);
insufficient effort in the monitoring (e.g. GAVI experience).
•
Problems of implementation: insufficient support, delays in the payment.
•
Cost-effectiveness of the strategy: high transaction costs (at system and facility
level) ; problem of comparator
•
Side-effect on the system
•
Side-effects for users: limited evidence so far, but potentially high.
•
Risks: crowding-out debate (a hypothesis).
•
Long-term effects, path dependency.
•
Sustainability
Our point: the debate should shift
away from a narrow vision of PBF
• Much could be said to ‘defend’ PBF on these
different points.
• Much could be said also to ‘defend’ the current
process.
• Our aim here is mainly here to outline our
broader view on PBF :
PBF is much more than an instrument to
improve ‘indicators’ which are remunerated («
MDG paradigm »), it fits in a broad reform vision.
PBF in a reform perspective
• Health system
• Public health services
• Governance of health care facilities
• Health labour market
• Public finance
• Governance of the public sector
Strenghtening the health system
• Requires the MoH to develop its role as steward, purchaser and
regulator.
• Can reorientate health care providers towards high impact
interventions (allocative efficiency).
• Can be very complementary to CBHI and be a major tool to move
towards universal coverage (including by being the mechanism to
remunerate providers delivering free health care).
• A mechanism to manage the distortion due to monies from Global
Health Initiatives.
• Improve the performance of the public health facilities (see below)
• Allow to integrate the private sector?
• Put the public and the private not for profit on a same foot.
%
Rwanda: Effect on MDGs High
Impact Interventions
100
90
80
70
60
50
40
30
20
10
0
2000
2007
% delivered in
a health
facility TOTAL
DPT3 (%)
Currently
Using any
modern FP
method (%)
% U5 who
slept under an
ITN the past
night
Increase in utilization of high impact
services
Trends in assistance at delivery : Years 2000, 2005, 2007
Percentage (%) of women delivered by a health
professional
Reforming public health system
and its health service delivery
• Higher coverage and quality of care.
• Can increase integration between different
levels of the health services (referral…).
• Can increase staff productivity (technical
efficiency)
• Can improve equity (e.g. equity bonus for
working in remote areas).
• Put pressure on ancillary units (e.g. central
medical store, programs).
• Improves the accuracy and responsiveness of
the health information system.
Reforming governance of health
care facilities
• A natural evolution of insitutional development in developing countries:
– Builds on and complementary to the Bamako Initiative;
– the ‘Great Lakes model’ = extending the logic of fees, to preventive services (with
a quality component), we ‘just’ change the identity of the payer (a third-party
payer instead of the user).
– Is a response to the need to establish a flow of public subsidy to facilities serving
the poor
• Induces a clarification of respective functions; reduce conflict of interest
• is complementary to greater autonomy of health facility managers (decision
rights on inputs).
• A role for the community actors in terms of accountability (cf. Burundi).
• Institutional autonomy is key
Reforming health labour market
• A reform which can be complemented by
other reform (cf. Rwanda)
• A potential response to the limits reached
by postcolonial civil service systems
• Increase staff motivation, reduce
absenteeism, stabilise the personnel
• Value entrepreneurship
Total health personnel in publicly funded facilities has
almost doubled in 3 years …
Total staff
14000
13133
12000
10000
8000
Total staff
6961
Linear (Total staff)
6000
Linear (Total staff)
4000
2000
0
2005
2008
Financing has more than tripled in four years (going from USD 7.5 to 30.3
millions, of which the PBF
has grown more than tenfold from USD 0.8 to 8.9 millions)
25
21.4
20
18.5
Basic salaries (Million USD)
15
Performance based financing
(Million USD)
11.2
Linear (Basic salaries (Million USD))
10
8.9
Linear (Performance based financing
(Million USD))
8
6.7
5
3.6
0.8
0
2005
2006
2007
2008
Proportion of of institutional deliveries
Delivery at the health facility increased overall in
Rwanda, but 7% more in PBF facilities between 20062008….
60.0
55.6
49.7
50.0
7.3 % increase
due to PBF
40.0
36.3
34.9
30.0
Baseline (2006)
Control facilities
Follow up (2008)
Treatment (PBF facilities)
19
Reforming public finance for health
• Consistent with budget support (but also SWAp).
• Resources are brought to the frontline providers,
no leakage.
• Consolidate the position of the MoH in front of
the MoF (relatively to other sectors for which
PBF is less relevant): clear link between funding
and outcome
Evolution of Primary Health Spending
Rwanda 2004-2007
8,000.0
7,000.0
million FRW
6,000.0
5,000.0
Community Health Schemes
Micro-insurance (mutuelles)
Performance Based Contracts
(PBC) for health facilities
4,000.0
3,000.0
2,000.0
1,000.0
0.0
2004
2005
2006
2007
Log Expenditures
Year
2006
2008
Treatment
15.812
(1.042)
16.906
(0.71)
Control
15.612
(1.007)
16.989
(1.08)
Difference
0.200
0.241
-0.083
(0.14)
P-Value
0.418
0.568
• Randomization balanced baseline
• Follow-up balanced, so difference in follow-up
outcomes due to incentives not resources
Reforming governance of the State
and the public sector
• The split of functions reveals that the MoH should not
control all the ‘knobs’.
• A better view on which decision and earning rights
should be decentralised at local level (on the ‘how’ not
on the ‘what’!). A lot of wrong has been done by public
finance and ‘decentralisation’ experts.
• More broadly a wonderful entry point to reform the
general governance in poorly governed countries (the
stress on performance and the obligation to deliver
results).
Strengthening accountability in the health sector in
Rwanda
NATIONAL GOVERNMENT
VOICE
Umushyikirano, Citizen
Report Cards,
Ombusdman
Clients / Citizens
COMMUNITY
GOVERNANCE
COMMUNITY HEALTH
INSURANCES
Mutuelles
PERFORMANCE BASED,
CASH AND IN KIND
INVESTMENT INPUT
SUBSIDIES TRANSFERS
LOCAL GOVERNMENT
Performance
CONTRACTS
CLIENT POWER
AUTONOMOUS
FACILITIES PROVIDERS
COMMUNITY HEALTH
WORKERS PROVIDERS
CCL: PBF fits a broader effort to
revise property rights
• PBF is part of a broader reform agenda.
• This agenda aims at consolidating the property rights of
the poor on public resources (cf. Reaching the Poor
report, Meessen 2009). ‘Voice’ has limits, let us play the
‘exit’ route (Hirschman 1970).
• Let us remain pragmatic and focus on our objectives.
• Having the broad view will indeed avoid ill-designed PBF
experiments / policies.