Millions Saved by Amanda Glassman

Author:Amanda Glassman
Language: eng
Format: mobi, epub
ISBN: 9781933286938
Publisher: Brookings Institution Press
Published: 2016-05-12T12:00:00+00:00

The Pay-for-Performance Scheme in Action

Typically, health workers in low- and middle-income countries are paid a fixed salary according to their education, position, and seniority. In other words, the salary does not depend directly on the number of patients served or the quality of care provided. In contrast, P4P schemes tie at least part of providers’ remuneration directly to various aspects of their job performance, such as the number of people seen or services provided, the quality and appropriateness of those services, and sometimes their patients’ health outcomes.

In Rwanda, P4P incentive payments were tied to health centers’ provision of 14 different services for maternal, child, and general health, ranging from US$0.09 for a first prenatal care visit to US$4.59 for a facility-based delivery or emergency obstetric referral.26 Four of the indicators rewarded appropriate referral of complex cases to higher levels of care; for those, reimbursement occurred only if hospital documentation confirmed that the referral was medically necessary. In addition, the government incentivized the provision of a range of HIV and tuberculosis services with similar per-unit performance payments.

The incentive payments were calculated according to a formula based on the quantity and coverage of health services, and then adjusted according to the quality of service delivery.

Each month, facilities forwarded their service provision records to a district committee. The committee first calculated the total incentive payment for each service by multiplying the reimbursement rate for that service by the number of times that service was provided. Then the incentive payments for all 14 indicators were added together to determine the total “base” payment amount for the facility.27 Once each quarter, auditors made surprise visits to each facility, checking for inconsistencies or misreporting. Generally, few discrepancies were found, although some clever “gaming” may have evaded detection.

To motivate health workers to deliver high-quality care, facilities’ overall base incentive payment was adjusted based on the quality of care they provided. In other words, a facility would receive only a portion of its base incentive payment if it scored low on a quality metric. This quality check was performed each quarter by a local district hospital supervisor.28

Quality is notoriously difficult to measure objectively. For the purposes of this program, the quality was calculated using standardized tools such as a quality score that incorporated 13 dimensions of facility conditions and patient care. Each facility’s monthly base incentive payment was multiplied by its most recent quality score, and the resulting product was disbursed as the final incentive payment.29 Facilities received the incentive payments with no strings attached and were free to allocate those funds as they saw fit. Most of them used the funds to top up staff salaries, on average by 38 percent over preincentive levels.30

The scheme was not without its problems. Some Rwandan health workers reported that the program distorted their prioritization, requiring them to use scarce time to complete the administrative tasks (filling out forms) required to get paid at the expense of providing critical care to their patients.31 Some health workers tried to game the system by filling out patient charts with services that had not been provided.

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