Paulin BASINGA Senior Program Officer Global Health Program, HIV Pay for Performance as an efficient Policy tool to improve health Outcomes and achieve greater E2S of AIDS programs ? Paulin BASINGA Senior Program Officer Global Health Program, HIV 19, 03, 2012 © 2009 Bill & Melinda Gates Foundation

Plan of the presentation Evidences and potentials of P4P to achieve greater E2 for HIV services Pay for performance: issues and challenges from a local perspective Sustainability issues around pay for performance of local E2S initiatives The Bill and Melinda Gates Foundation E2 work globally © 2012 Bill & Melinda Gates Foundation |

Introduction In the current context of scarce resources for development, achieving better value for money for HIV/AIDS services, programmes and policies is essential. More money for health – more health for money report recommendation1 : Allocations of all future funds should be linked to clear expectations of outcomes and results, and linked to a mutually agreed medium-term fiscal framework. A particular focus will be on using Results-Based Financing to improve access to vital health services for women and vulnerable groups. (Source : Taskforce on innovative international financing for Health Systems.)

Results-based financing: Results-based financing refers to a range of mechanisms including output-based aid, results-based loan “buy-downs”, provider payment incentives, and conditional cash transfers. The conditions for successful implementation of results-based financing include independent evaluation and “verification” of services provided, and effective arrangements for quality assurance. Finding the right approaches varies with country context. Exchanges of experience by practitioners in different countries continue to be promoted.

PBF is only one of many other provider motivation initiatives … Source : Touré et all. BMC Public Health 2010, 10:702

Incentives have been used to increase delivery and uptake of HIV services… Use of Incentives for HIV services Supply side incentives (health facilities, providers, ..) Demand side incentives (CCT , CT) Rwanda Haiti Ivory cost Mozambique Malawi Tanzania South Africa

Demand sides incentives, evidences for HIV services… © 2012 Bill & Melinda Gates Foundation |

There are few available evidence on the effect of CT/CCT on HIV related behavior and incidence, the causal pathway still need to be clearly elucidated…. Demand side incentives Malawi, Zomba Baird SJ, Ozler B. 2012 Malawi Hans- P Kohler, 2011 Malawi, HIV tesT Thorton RL, 2008 Tanzania De Walque D, et all. 2012 September 20, 2018 © 2010 Bill & Melinda Gates Foundation |

Available evidences Demand side incentives Malawi, Zomba Baird SJ, Ozler B. 2012 Malawi, HIV tesT Thorton RL, 2008 Malawi Hans- P Kohler, 2011 Tanzania De Walque D, et all. 2012 RCT, 1 year Girls or mother received 10$ conditional to girl attending school Girls / mother received cash unconditional 60% reduction in HIV incidence - Girls who received cash were : Less likely to be pregnant Married early Engage in sexual activities or sexual risk behaviors. No difference in conditionality September 20, 2018 © 2010 Bill & Melinda Gates Foundation |

Available evidences Demand side incentives Malawi Tanzania Malawi, Zomba Baird SJ, Ozler B. 2012 Malawi, HIV tesT Thorton RL, 2008 Malawi Hans- P Kohler, 2011 Tanzania De Walque D, et all. 2012 Incentives and HIV testing Small incentives (< 1/10th day wage )double the rate of results seeking. Sexually active HIV-positive individuals who learned their results were 3 times more likely to purchase condoms two months later than sexually active HIV-positive individuals who did not learn their results. However, HIV-positive individuals who learned their results purchase only 2 additional condoms than those not incentivized to receive test results. September 20, 2018 © 2010 Bill & Melinda Gates Foundation |

Available evidences Demand side incentives Malawi, Zomba Malawi Baird SJ, Ozler B. 2012 Malawi, HIV tesT Thorton RL, 2008 Malawi Hans- P Kohler, 2011 Tanzania De Walque D, et all. 2012 3-4 months wage cash transfer offered to women and men had no effect on HIV status or on reported sexual behavior during the incentive year. But once the incentive was paid, cash had strong negative effects on men and positive effects on women Questioned the unconditional cash transfer September 20, 2018 © 2010 Bill & Melinda Gates Foundation |

Available evidences Demand side incentives Malawi, Zomba Baird SJ, Ozler B. 2012 Malawi, HIV tesT Thorton RL, 2008 Malawi Hans- P Kohler, 2011 Tanzania De Walque D, et all. 2012 Adult men were randomized to receive 10$, 20$ or nothing after a test each 4 months. Funds conditional to remain free of STI Participants every 4 months over a 12-month period for the presence of common sexually transmitted infections. . 25% decrease in STI due to cash transfer Size of incentive matters. September 20, 2018 © 2010 Bill & Melinda Gates Foundation |

Planned and ongoing initiatives Demand side Incentives, cont South Africa HPTN 068, Ongoing Tanzania (Iringa) David D. C et all. ? On going… Research question: Young women who are randomized to receive cash transfers conditional on school attendance have a lower incidence of HIV infection over time compared to young women who are not randomized to receive cash transfers? Results 2015 ? HIV combination prevention study Planning process… September 20, 2018 © 2010 Bill & Melinda Gates Foundation |

Supply side incentives, conceptual framework and evidences for HIV services… © 2012 Bill & Melinda Gates Foundation |

Potential of P4P on technical efficiency improvement Production Possibility Frontier What They Do: (Services/ Quality) Q T What They Have (Ability/Technology)

Productivity Gap: Difference between potential and actual Production Possibility Frontier What They Do QP Productivity Gap for Ability Level T = QP – QA Actual Performance for most countries QA T Ability/Technology

Productivity is Higher For Better Providers, But Less Than It Could Be What They Do Actual Performance QP1 QA1 T1 T2 Ability/Technology

But, Productivity Gap is also Higher For Better Providers What They Do QP2 Productivity Gap Conditional on Ability QP1 QA2 Actual Performance QA1 T1 T2 Ability/Technology

Impact of traditional supply side interventions (T1 to T2) less than could be What They Do QA2 Actual Performance QA1 T1 T2 Ability/Technology

P4P moves actual performance closer to PPF and increases the impact of traditional interventions What They Do QAp4p Impact of P4P QA T2 Ability/Technology T1

Impact of Pay for Performance in Rwanda : Baseline results

After 2 years of P4P implementation: Technical Inefficiency 45o Line -- Production Possibility Frontier

HIV Contracted indicators P4P, Rwanda    Service Indicators remunerated in quarterly basis Amount paid by P4P per case (US$) 1 HTC Number of clients tested for HIV at the HTC center 0.92 2 HTC / PMTCT Number of couples/partners tested during the reporting month 4.59 3 PMTCT Number of HIV+ pregnant women on ARV treatment during labor 4 Number of infants born to HIV+ mothers tested 9.17 5 Care Number of HIV+ patients who received CD4 test 6 Number of HIV+ patients treated with co-trimoxazole each month 0.46 7 ARV Number of new HIV+ adults on ARV treatment 8 Number of new HIV+ infants on ARV treatment 6.88 9 HIV Prevention Number of HIV+ women on contraception 2.75 10 Total number of HIV+ patients tested for tuberculosis

Estimated impact of PBF on HIV Testing and Counseling: HIV testing and counseling among adults (>15years) not identified as HIV patients %∆^(***)=(β⁄(Baseline mean))*100 , where the baseline mean equals the mean of the dependent variable for the intervention group at baseline (2006). Damien de Walque et all. The Effect on HIV Testing and Counseling Services in Rwanda of Paying Health Care Providers for Performance: an Impact Evaluation. Under review.

HIV-PBF experience in Mozambique EGPAF is implementing a pilot in 2 provinces 12 months of implementation A total of 21 indicators contracted 5 non – HIV indicators Quality multiplier Equity multiplier Evaluation ongoing

PBF potential use of incentives for MC ? Supply side (PBF) Paying overtime for MC delivery (week ends, campaign,..) Number of procedures performed? (defector?) Quality measurement? Bonus to facility? Or to individual? Demand side (CCT / CT) Transport cost reimbursement Cell phones card (Kenya) for bringing a friend,… Incentive to come back for wound healing consultation?

Issues and challenges from a local perspective Context matters, good planning (equity, indicators prices,) Health reform, need the government authorities leadership Performance appraisal, supervision..: Reliance on facility HMIS data Limited assessment of less or non-incentivized services Limited look at how PBF works, for which populations it works, and the duration of effect Health financing at the health facility : autonomy

Sustainability issues around pay for performance of local E2S initiatives Importance for external aid to be catalytic: need to focus on results and efficiency gains In order to prevent dependence, governments need to work with donor to set clear time frames for phase-out of increased assistance Countries should develop their own plans for domestic resource mobilization. Ministry of Health leadership, central level. Integration +++ Fiscal space

BMGF HIV Theory of Action identified strategic initiatives in the following areas: © 2009 Bill & Melinda Gates Foundation

Effectiveness and efficiency portfolio Modeling Treatment Optimization Prevention Effectiveness Management Cross-cutting Categorizing epidemics; Prevention strategies; Diagnostics; Patient management; September 20, 2018 © 2010 Bill & Melinda Gates Foundation |

Effectiveness and efficiency portfolio Modeling Treatment Optimization Prevention Effectiveness Management - Cost and Cost-Effectiveness Analyses (patient, facility, costs drivers,..) - Drug Optimization (process & formulation chemistry,..) - Laboratory optimization (POC diagnosis, platform,..) - System of delivery (decentralization, integration, task shifting,..) September 20, 2018 © 2010 Bill & Melinda Gates Foundation |

Effectiveness and efficiency portfolio Modeling Treatment Optimization Prevention Effectiveness Management Combination prevention Community randomized trials including treatment as prevention (In partnerships) September 20, 2018 © 2010 Bill & Melinda Gates Foundation |

Effectiveness and efficiency portfolio Modeling Treatment Optimization Prevention Effectiveness Management To what extent can better management help to achieve our objectives for treatment and prevention optimization? September 20, 2018 © 2010 Bill & Melinda Gates Foundation |

BMGF policy on RBF The foundation does not have any policy with regard to RBF Focus on potential of technology and innovation to bring down the costs and increase access to the poor. Interest in innovations on services delivery and financing models that can work in developing countries The foundation support indirectly PBF approaches through its contributions Global Fund and GAVI Interest to learn more on how RBF can be used to increase uptake of services such as Male circumcision?

Thank You © 2012 Bill & Melinda Gates Foundation. All Rights Reserved. Bill & Melinda Gates Foundation is a registered trademark in the United States and other countries. © 2009 Bill & Melinda Gates Foundation