1. Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane Universitys School of Public Health Training Resources Group Catalyzing Maternal and Child Health Results by Paying for Performance: Evidence from Developing Countries Catherine Connor and Rena Eichler Health Systems 20/20 Project 15 November 2010 Health Systems Research Symposium

2. What does pay for performance have to do with reaching universal coverage? Feasibility of Insurance Design and Implementation Monitoring and Evaluation Financing options Benefits package Pop Coverage Opera- tions Organiza- tional structure Provider engage- ment Incentives to use priority services Pay providers for quality or efficiency Incentives to cover hard-to-reach populations

3. Presentation Objectives What is Pay for Performance? Highlights from on-line survey of country experiences Expanding access for maternal and child health results: the case of Burundi

4. What we mean by P4P Funds, Goods, Other Payer Donars. Govenment, NGOs Health Programs, Insurers Recipient Patients or Families Service Providers (facility or health worker) NGO or program implementer Government - Local or National Results Demand Side Supply Side

5. What is P4P? Many terms: results-based financing, performance- based financing, performance-based contracting, conditional cash transfers, … One common definition: Transfer of money or material goods conditional on taking a measurable health related action or achieving a predetermined performance target * *From the Center for Global Development Working Group on Performance-Based Incentives

6. Pay-for-Performance (P4P) An explosion of interest and funding

7. Flat salaries for providers leads to low incentives to provide quantity or quality or to serve the poor Fixing incentives is important complement to infrastructure, technical, and capacity building interventions P4P can be combined with any provider payment method: Salary, FFS, capitation, case-based, global budget Why is P4P getting so much attention?

8. Snapshot of P4P Country Survey Why do this survey? To fill the gap between growing experimentation and little documentation Global online survey 2009 90 e-responses 25 responses summarized 14 longer case studies in 2010

9. Distribution of 25 cases by region AfricaAsiaLatin American and the Caribbean Europe and Eurasia Middle East Benin Burundi (2) DRC(2) Ethiopia Ghana Kenya (3, 1) Rwanda Tanzania Uganda Zambia Bangladesh Cambodia (2) India Philippines Belize Brazil Honduras ArmeniaEgypt 155311

10. Survey results: Purchasing focused on priority services Maternal health results dominate (22/25). Child health results also top priority (14/25). Infectious (e.g. HIV/AIDS, malaria) and non- communicable diseases (e.g. cancer screening, diabetes and asthma management) included but less frequent

11. Primary care facilities Rural or peri-urban areas Community outreach Demand side (users/patients) - vouchers and transportation subsidies Increasing attempts to reward quality Survey results: Designs to expand access

12. BURUNDI Public-private purchasing to increase use of priority services and improve quality

13. What drove interest in PBF in Burundi? Facility use rate (consults/year/person) 1 0.47 (2004) Births attended by qualified staff 1 9.8% (2004) DTP3 immunization 1 54% (2004) Measles immunization 1 50% (2004) Contraceptive prevalence rate 2 9% (2005) U5 sleeping under insecticide-treated net 2 8% (2005) 1. Kaneza 2007; 2.http://healthsystems2020.healthsystemsdatabase.org/

14. $ $ Facilities report utilization each month Monthly payments fee for service + quarterly bonus for quality TechnicalAssistance HealthNetTPO Cordaid P4P Purchasing – how it works Quality Assess Community survey

15. Number of women using contraceptive methods doubles Burundi Results – Kibuye Province

16. Using P4P to expand access in developing countries Many different designs Focus on maternal and child health Majority are supply-side (provider) Some are demand-side (user) Clear need for more documentation to learn what is working and learn how design and implementation challenges are being overcome

17. Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane Universitys School of Public Health Training Resources Group Thank you Reports related to this presentation are available at www.HS2020.org