Sub-optimal performance of health systems in low and middle-income countries (LMICs) is a major concern for policy makers (Lannes 2015). Increased funding for health has not necessarily translated into better health outcomes, thereby leaving policy makers searching for alternative approaches to improve the performance of their health systems (WHO 2000). A key reform being widely explored in LMICs, is performance-based financing (PBF) - a methodology for financing health care which introduces incentives to reward the achievement of predefined health services. As early as 1993, the World Bank recommended use of incentives as a way to address service delivery bottlenecks in LMICs. The underlying rationale for this approach was that well-designed incentives in such countries can help improve the production of health care services and harness innovation at various levels of the health care system (Filmer, Hammer, and Pritchett 2000). Health care delivery in LMICs is labor intensive, with a direct link between the quality and efficiency of health provision and the extent to which health workers apply themselves to their tasks (Witter et al. 2013). However, there is limited evidence from LMICs contexts on the effect of PBF on various dimensions of health systems including its effects on health worker satisfaction and on quality of care. In addition, there is a dearth of evidence on the extent to which contextual factors mediate the PBF’s effects on quality of care.
The first analysis is a systematic review of relevant literature focused on PBF and its effects on job satisfaction/motivation of health workers and on quality of care in LMICs. Qualitative and quantitative studies on PBFs in LMICs published between 2000 and 2016, with a focus on quality of care and health worker job satisfaction and published in English were also assessed further for inclusion. Opinion papers, editorials and individual case studies were excluded from the review. A total of 31 papers met the inclusion criteria.
Results suggest that PBF has a positive but mixed effect on quality of health care services (process, structural and outcome quality), especially among maternal, newborn and child health (MNCH) services. Outcome quality is the least measured quality of care component and literature on health worker job satisfaction in LMICs was limited. However, evidence suggests that PBF programs in LMICs can enhance job satisfaction—particularly, when a PBF incentive scheme is complemented with strategies that promote participation and engagement between health providers and managers in health care systems. Evidence also demonstrated that PBF incentive schemes that were viewed as fair, clearly communicated, and coupled with opportunities for advancement, training and promotion, could also enhance job satisfaction. Health care worker satisfaction is critical to improving the quality of health care in LMICs, and PBF is one promising tool that can help. However, incentives alone cannot offset contextual challenges. Each PBF model must be strategically designed, planned and rolled out—with active involvement and input from beneficiaries of these programs (health workers and managers) —with careful attention to context-specific obstacles and opportunities. More evidence on PBF in LMICs is needed, particularly related to job satisfaction of health workers and outcome quality.
The second and third analyses investigated the effects of PBF in Zimbabwe. The manuscripts are based on an analysis of data from an impact evaluation of the PBF program in Zimbabwe.
In the second analysis, a quasi-experimental design (difference-in-differences [DID]) was used to examine the impact of PBF on health worker satisfaction outcomes including the following: relationship with staff and supervisors within facilities as well as at the district level, working conditions, staff self-assessment of performance compensation, recognition and career development. The impact evaluation was completed across 32 rural districts—16 intervention and 16 control —with two rounds of data collection between February 2012 and September 2014. PBF is estimated to have a statistically significant effect of approximately 7.8 percentage points (p < 0.01) on compensation for health workers, with insignificant impacts on all other outcomes. In Zimbabwe, the PBF scheme brought about a significant increase in satisfaction with increased compensation, however, there was no significant impact on other dimensions of health worker satisfaction. This lack of significant impact on other dimensions of health worker satisfaction is linked to Zimbabwe’s broader human resources for health (HRH) context and challenges, which PBF financial incentives alone are not able to address.
In the third analysis, a DID analysis was used to estimate PBF’s effect on quality of care for specified Maternal and Child Health (MCH) services. A composite quality of care measure (QoC) was constructed by summing up the quality measures for the five MCH services, i.e. Antenatal care (ANC), post-natal care (PNC), expanded program on immunization (EPI), and delivery and curative care. The DID method compares the change in quality of care in the PBF group to the change in outcomes in the control group.
The analysis was carried out in two stages. The first stage measured the effects of PBF on quality of care and the second stage measured the extent to which contextual factors at the baseline influenced the effects of PBF on quality of care measures. Contextual factors were classified into three categories: 1) fixed and beyond health facilities control variables, 2) variables that were under the influence of the health systems and 3) variables that were directly influenced by the PBF program.
Overall, PBF was found to have no effect on quality of care for all five services apart from institutional deliveries. PBF improved quality of institutional delivery by 0.01 percentage points. Results of individual contextual factors on their impact of PBF on quality of care were varied. An increase in the distance between health facilities and communities decreased the impact of PBF on quality of care by about 1.21% (p=0.0020), while distance from the district capital had no impact on PBF’s effects on quality of care (QoC). Catchment areas size, mean population wealth and availability of skilled health workers had no impact on PBF effects on quality of care. However, job satisfaction of health workers significantly increased the impact of PBF on quality of care by 27.7% (p<0.0001).
The role of such a contextual factor within the control of policy makers, points to the importance of understanding the significance of those contextual factors that are influenced by the health system and those influenced by programs.
|Commitee:||Markus, Anne R., Zeng, Wu|
|School:||The George Washington University|
|School Location:||United States -- District of Columbia|
|Source:||DAI-A 81/8(E), Dissertation Abstracts International|
|Subjects:||Public health, Economics, Health sciences|
|Keywords:||Health system performance, Health workers, Incentives, Performance|
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