1. 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

2. 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 |

3. 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.)

4. 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.

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

6. 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

7. Demand sides incentives, evidences for HIV services…
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8. 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 |

9. 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 |

10. 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 |

11. 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 |

12. 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 |

13. 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 |

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

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

16. 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

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

18. 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

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

20. 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

21. Impact of Pay for Performance in Rwanda : Baseline results

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

23. 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

24. 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.

25. 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

26. 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?

27. 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

28. 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

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

30. 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 |

31. 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 |

32. 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 |

33. 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 |

34. 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?

35. 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