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Paying Health Care Providers for Performance: Evidence from Rwanda. Paul Gertler UC Berkeley January 2009. Collaboration. Research Team Paulin Basinga, National University of Rwanda Paul Gertler, UC Berkeley Jennifer Sturdy, World Bank

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paying health care providers for performance evidence from rwanda

Paying Health Care Providers for Performance: Evidence from Rwanda

Paul Gertler

UC Berkeley

January 2009

  • Research Team
    • Paulin Basinga, National University of Rwanda
    • Paul Gertler, UC Berkeley
    • Jennifer Sturdy, World Bank
    • Christel Vermeersch, World Bank
  • Policy Counterpart Team
    • Agnes Binagwaho, Rwanda Rwanda MOH
    • Agnes Soucat, World Bank
  • Background/Motivation
  • Rwanda
  • Program Description
  • Evaluation Design and Methodology
  • Baseline Descriptive Statistics
  • Impact of PBF
  • Next Steps
context developing world
Context: Developing World
  • Africa
    • Very poor health status
    • Weak health care systems
    • Brain drain – doctors & nurses leaving
    • Massive AID could be wasted
  • World Wide (WDR 2004)
    • Low Quality of Care
    • Training/technology have had small effect on Quality
    • Provider absenteeism high & effort low
pay for performance
Pay For Performance
  • Pay Medical Providers a bonus based on performance measurement
    • Improve quality of care and outcomes
    • Improve job satisfaction & retention
  • Organization Challenges
    • Individuals versus team incentives
    • Measuring performance
    • Cheating/Misreporting
rwanda central african country
Rwanda: Central African Country
  • 9 million people
  • Genocide in early 1990s
  • GNP per capita: 250 US$
  • Weak Health Care Infrastructure
    • 36 Hospitals, 369 health centers
    • Doctors: 1/50,000 inhabitants
    • Nurses: 1/3,900 inhabitants;
    • 17% of nurses in rural areas
  • Poor health status, but getting better
performance based financing pbf
Performance-based Financing (PBF)
  • Local Initiative
  • Objectives
    • Increase quantity & quality of health services provided
    • Increase health worker motivation
  • Financial incentives to providers to see more patients and provide higher quality of care
    • Increased resources
    • Financial incentives
  • Operates through contracts between
    • Government
    • Health facilities providing services
quarterly payment to facility i in period t
Quarterly Payment to Facility i in period t

Pj = payment per unit of each PBF service j

Uijt= number of patients using service j in facility i in period t

Qit = facility i’s quality in period t

pbf facility quality score
PBF Facility Quality Score

Where Skit = facility i’s Quality index of Service k

  • Indicator types:
    • Structural: Availability of medical equipment/drugs needed to deliver adequate medical care
    • Process: Clinical content of care (CPGs)
monitoring facility reporting
Monitoring Facility Reporting
  • District Comite de Pilotage
    • Approves quarterly payment
    • Based on facility reports & independent audits
  • Random utilization audit (once quarterly)
    • One focal point per administrative district
  • Random quality audits (once quarterly)
    • District supervisors based in District Hospital
  • Interview random sample of patients
    • Identify phantom patients
    • MSH study – less than 3-5% phantom patients
evaluation questions did pbf
Evaluation Questions: Did PBF…
  • Increase the quantity of contracted health services delivered?
  • Improve the quality of contracted health services provided?
  • Improve child health status?
identification strategy
Identification Strategy
  • During decentralization, phased rollout at district level
  • Identified districts without complete PBF in 2005
  • Group districts into “similar pairs” based on population density & livelihoods
    • Decentralization reallocated districts
    • Some new districts had PBF in an area of the new district
    • Gov’t rolled PBF to remaining clinics (treatments)
    • Districts matched to these partials controls
    • Others: randomly assign one to treatment and other to control
    • 8 pairs
isolating the incentive effect
Isolating the incentive effect
  • PBF
    • Performance incentives
    • Additional resources
  • Compensate control facilities with equal resources
    • Average of what treatments receive
    • Not linked to performance
    • Money allocated by the health center management
  • 165 health facilities
    • all rural health centers located in districts
  • 2145 households in catchment areas
    • Random sample of 14 per clinic
  • Panel data: 2006 and 2008
survey content
Survey Content
  • Health Facility Data
    • Financials and Human resources
    • Lab test, equipment and medicine availability
    • Provider interview for competency (vignette)
    • 8-10 patient exit Interviews for prenatal process quality
  • Household survey
    • Socio-economics
    • Utilization
    • Health outcomes
health facility results
Health Facility Results
  • Did we isolate incentives effect?
    • Log expenditure between Tr and Phase II
  • Did randomization balance treatment/control groups?
  • Did utilization increase?
  • Did structural quality improve?
  • Did process quality improve?
    • Prenatal Care (PBF pays for this)
    • Child Curative Care (PBF does not pay for this)
log expenditures
Log Expenditures
  • Randomization balanced baseline
  • Follow-up balanced, so difference in follow-up outcomes due to incentives not resources
baseline balance
Baseline Balance
  • Utilization (PBF)
  • Structural Quality
    • Availability of staff, equipment & drugs needed to deliver care (PBF)
    • Little room to improve
  • Process Quality
    • Competency (Vignettes)
    • Process Quality (Patient exit survey)
prenatal competency quality
Prenatal Competency & Quality
  • Standardized vignette presented to provider
    • Unprompted responses for competency
    • Measure of ability/knowledge
    • Based on Rwandan Clinical Practice Guidelines
  • Process quality
    • Patient exit interview for process quality
    • Clinical content of care
    • Provider effort
quality conceptual framework
Quality Conceptual Framework




What They Do: (Quality)

What They Know (Ability/Technology)

returns to training technology low data from 12 countries
Returns to Training/Technology low (data from 12 countries)


What They Do

Actual Performance

Ability/Technology (More Training & Equip/Drugs )

goal use pay for performance to close productivity gap
Goal: Use Pay for Performance to Close Productivity Gap


What They Do

Productivity Gap Conditional on Ability

Actual Performance


impact of pbf statistical methods
Impact of PBF: Statistical methods
  • Have balance at baseline on all key outcomes
  • Use difference in differences analysis
    • Not a pure randomized experiment
  • Clustered at district year level
  • Facility Fixed Effects
  • Year dummy
  • Controls: age, parity, education, household size, health insurance, land, value of assets
impact on child height
Impact on Child Height
  • 0-11 months = +0.28***
  • 24-47 months = +0.86***
results summary
Results Summary
  • Balanced at baseline
  • Expenditures same, so isolate incentives
  • Impact on utilization
    • Delivery & Child prevention, but not prenatal
  • Impact on prenatal quality
    • Bigger for better doctors
  • Reduced child morbidity
  • Taller children