Impact of a Provider Incentive Payment Scheme on the Quality of Reproductive and Child Health Services in Egypt

1. International Workshop Incentive schemes and performance of health care providers in Low-Income Countries: recent developments, risks and emerging challenges Impact of a Provider Incentive Payment Scheme on the Quality of Reproductive and Child Health Services in Egypt Dale Huntington, Hassan Zaky, Sherine Shawky, Fatten Abdel Fattah, Eman El-Hadary CERDI, Clermont-Ferrand, France 17-18 December 2009

2. Introduction • Egypt is a lower middle income country in the EMR and second populous • The Government of Egypt is committed to improve population health and well-being • The Government of Egypt is undergoing major reforms including the health sector

3. Introduction (cont.) By the beginning of the 1990s, the Government of Egypt realized several pressing challenges in the health sector • Health equity became a significant problem • Public spending was regressive • Health sector was burdened with a mix of centralized and decentralized functions • Health sector’s financing was fragmented and uncoordinated • There were surpluses and imbalances of health care personnel

4. Egypt Health Sector Reform Program Pilot Phase in 1998-2004 Focusing on Primary Health Care Creating Family Health Fund Introducing Basic Benefit Package Piloting set of reforms targeting incentive payments to health care providers Introduction (cont.)

5. Description of the Incentive Payment Scheme • Amount may reach up 275% times the total base salary • Payments are based on performance indicators • Weights are set giving attention to priority programs • Numeric scores are used in calculating the incentives

6. Evaluation of the impact of a Provider Incentive Payment Scheme on the Quality of Reproductive and Child Health Services in Egypt Egypt Ministry of Health and Population The Social Research Center, American University in Cairo Reproductive Health and Research Department, World Health Organization, Geneva

7. Hypothesis Providers who receive the incentive payment will provide better quality reproductive health services and be more responsive to clients’ reproductive health needs than providers who receive a salary supplement not linked to performance

8. Method Incentive (2 PHCUs) Non-incentive (2 PHCUs) Menoufia Quesna Five Governorates Incentive (2 PHCUs) Non-incentive (2 PHCUs) Suhag Maragha Pilot Incentive Payments Purposive Sample In-depth interviews (DPOM & HCP ) Checklist Clients’ exit interview

9. Findings Primary Health Care Units (PHCUs) Description Case Load Women’s (15-49 years) exit interview Reasons for seeking care in PHCUs Family planning services Antenatal Care services Child care services DPO managers and health care providers

10. Description of the Primary Health Care Centers

11. Reproductive Health Case Load

12. Child Care Case Load

13. Reasons for seeking health care in the incentive and non-incentive primary health care units of the two Egyptian governorates

14. Quality of Family Planning Services

15. Responsiveness of Family Planning Services

16. Quality of Antenatal Care Services

17. Responsiveness of Antenatal Care Services

18. Quality of Child Health Care Services

19. Responsiveness of Child Health Care Services

20. Positive Operating according to HSRP guidelines and procedures Availability of medicines especially for chronic diseases The 24-hour services benefit people especially in remote villages Is a motivating system for health care providers Negative Costly and unacceptable for clients Heavy routine procedures Confusing phased introduction Use too many detailed indicators Indicators are established by decision makers without consulting the administrations or health care providers Calculations of incentives are not clear for physicians The delay in receiving incentives is very depressing for workers There is no clear training plan and no certain responsible department DPO Managers and Health Care Providers

21. Conclusion • Providers who were paid with the incentive payment scheme were more likely to deliver higher quality of care and better responsiveness • Physicians do better on medical care indicators than on responsiveness indicators • The incentive scheme units appear to be more responsive to beneficiaries than the non-incentive scheme units • Inadequate responsiveness to beneficiaries’ masks the improvement in quality of care in incentive scheme units • Sustained attention is required for continual quality improvement