Performance-Based Incentives for Voluntary Family Planning: Why So Important and How to Do it Responsibly

1. Performance-Based Incentives for Voluntary Family Planning:Why So Important and How to Do it Responsibly Rena Eichler and Lindsay Morgan renaeichler@broadbranch.org October 8, 2010 USAID Mini-university

2. PBI is happening in a big way • USAID in Egypt, Ghana, Haiti, Liberia, South Sudan and Rwanda and smaller programs in Honduras, DRC, Kenya and Pakistan. GHI emphasizes PBI. • World Bank RBF pilots to implement and evaluate RBF in 9 countries with $420 million from the UK and Norway. • Norway bilateral support of PBI for MNCH in India, Malawi, Nigeria, Pakistan and Tanzania. • Germany supporting PBI in Malawi and Output Based Aid voucher programs in Kenya and Uganda. • Inter-Agency Working Group on RBF • DFID is emphasizing results based financing • AUSAID has performance based financing window • EC support for performance based incentives • GAVI HSS window can be used for PBI (ex: Afghanistan). • Global Fund

3. Formal definition Performance-Based Incentives (PBI) is a “transfer of money or material goods conditional on taking a measurable health related action or achieving a predetermined performance target” * “No results, no payment” *From the Center for Global Development Working Group on Performance-Based Incentives

4. PBI is an opportunity and a challenge for family planning Opportunity: • Stimulate quality FP counseling, increase availability of modern methods to manage family size and space births, overcome access barriers • Build FP into broader PBI schemes Challenge: • Support voluntary and informed choice • Avoid potential neglect of FP if not included in the package of rewarded services

5. Why family planning? Potential global health impact of reducing unintended pregnancies from 75 million to 22 million: • Avert maternal deaths: 70% reduction from 550,000 to 160,000 • Avert newborn deaths: 44% reduction from 3.5 million to 1.9 million • Avert complications from unsafe abortions: women needing medical care for complications from unsafe procedures would decline from 8.5 million to 2 million. Source: Singh, Susheela, J. Darroch, and M. Vlassoff, 2009. Adding it Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health. The Guttmacher Institute and UNFPA. Washington, DC, December.

6. FP is good for development • Greater family savings • Better prospects for educating children • Strengthened economies • Reduced pressure on natural resources and the environment MDG Target 5b: Achieve universal access to reproductive health by 2015 • 5.3 Contraceptive prevalence rate • 5.4 Adolescent birth rate • 5.6 Unmet need for family planning

7. Some history… • India and Bangladesh paid providers and clients for each sterilization – raised concerns about coercion • In 1982, USAID introduced agency policy (“PD-3”) USAID missions were advised to: “Encourage patterns of service delivery and methods of payment which do not unduly emphasize voluntary sterilization services compared to other methods of ‘fertility control’” • In 1998, US Congress responded to evidence of non-voluntary practices in the Peruvian FP program with a statutory amendment referred to as the “Tiahrt Amendment”

8. US government rules: Focus on voluntarism and informed choice (specified in the Tiahrt Amendment) “Service providers or referral agents shall not implement or be subject to numerical targets or quotas of total number of births, number of family planning acceptors, or acceptors of a particular family planning method. Quantitative estimates or indicators used for budgeting or planning purposes are permissible” “No incentives, bribes, gratuities, or financial reward for family planning program personnel for achieving targets or quotas, or for individuals in exchange for becoming a family planning acceptor” full Tiahrt text: http://www.usaid.gov/our_work/global_health/pop/fy99lang.pdf

9. Some examples of PBI schemes that include voluntary FP • Women are sold vouchers at subsidized rates that enable them access to FP services at private and/or public facilities (Kenya, Pakistan) • Community health workers are rewarded for delivering a comprehensive package of maternal health services that include FP counseling (India, Philippines) • NGO contracts reward reduced FP discontinuation, increased FP utilization and, in some cases, improved quality of FP services (Haiti, Kenya, Liberia, S. Sudan) • Public sector providers receive money when FP services, such as new and continuing FP use, are delivered (Burundi, DRC, Egypt, Rwanda) • Fiscal transfers from national to sub-national levels of government are linked to FP performance (Argentina, Brazil) and funding from donors to countries is partly conditioned on FP results (regional Initiative in Central America, India)

10. Consider a health center in a developing country…

11. People are motivated by internal and external forces • Internal: e.g., professional pride, altruism • External: e.g., money, recognition, awards • PBI focuses on external motivation. Payment comes from an external source • Aim is to motivate with external rewards in a way that reinforces internal motivation

12. Possible pitfalls • Excessive attention to reaching targets, to detriment of other (harder to measure) types of performance • Incentivizing actions by either providers or clients that result in involuntary use of family planning methods • Undermining internal motivation, turning health care delivery into “piecework” • “Gaming,” including erosion in quality of institutions’ service statistics • Without clear communication, clients may incorrectly interpret the offer to cover transportation costs to access counseling or specific services (e.g. voluntary sterilization) as payment to accept a method

13. Do’s and Don’ts • Do consider rewarding: • reliable availability of commodities • quality counseling • reduced discontinuation • Facilities, teams, or sub-national levels of government • Don’t consider rewarding: • Individual health workers for attaining targets related to use. • Clients for adopting a modern method. Refer to handout for more detail

14. Some snapshots of PBI programs that incorporate voluntary FP

15. Plan Nacerin Argentina: Intergovernmental fiscal transfers linked to results Increase access to basic health services for uninsured mothers and children. Per head transfer 60% released upon monthly enrollment of eligible population, and 40% released for each of the 10 Tracers goals achieved Provinces establish provincial purchasing units Contract with public and private facilities Pay fee-for-service

16. Argentina “Snapshot” Maternal and child health insurance program for the poor in Argentina FP indicator: Proportion of Reproductive age women who receive counseling for sexual and reproductive health Recipients: Province-level governments FP-linked payment mechanism: 4 percent of per capita payment linked to attainment of FP target

17. Results

18. Health system changes • For the first time in Argentina’s public health sector, national financial transfers to the states are linked to verifiable results • Also for the first time, financing of public providers is done on the basis of delivery of services to eligible population • New output and outcome data is beginning to serve as basis for strategy and planning at provincial level • Social accountability has also increased significantly

19. Haiti: Performance contracts with NGOs • USAID project managed by MSH, contracts NGOs and pays partly on results • Pilot in 1999 rewarded 2 FP indicators • FP indicators subsequently dropped because of lack of clarity on what is allowable • Project continues today without FP indicators • FP use stagnated while rewarded services grew significantly

20. Haiti “Snapshot” Performance based contracting of NGOs FP Indicators: Availability of at least 5 modern methods; reduce FP discontinuation rate Recipients: NGOs FP-linked payment mechanism: Financial reward linked to attainment of annual target In USAID contract language: Fixed price subcontract (quarterly fixed payments) plus award fee

21. Some results from Haiti (1999-2005) • 13+ percentage point increase in immunization coverage. Translates to 15,000 additional children per contract period immunized because of PBI • 19+ percentage point increase in the number of women who delivered babies in health facilities with the assistance of trained attendants. Implies that 18,000 additional women gave birth more safely because of PBI • Results for increases in 3+ prenatal care visits and postnatal care were insignificant • FP indicators dropped after 1999 pilot • Availability of modern methods dropped because was a “give away” • Reduced discontinuation rate dropped because of concern about Tiahrt violations

22. Current challenges for PBI in Haiti • How to create capacity to manage PBI within the public sector? • How to expand geographic access? • How to continue to improve outputs? • How to revise and refine the model to continue motivation and overall improvement? • Long term sustainability of the approach?

23. Moving toward national PBF in Burundi • Inspired by Rwanda PBF and strong pilot results • Public facilities • Payment for FP use and quality • Aim to cover entire country by early 2010

24. Burundi “Snapshot” From pilot to scale up of PBF with public facilities FP Indicators: New FP acceptors, insertion of IUDs, implants Recipients: Health facilities FP-linked payment mechanism: Monthly payments of fees to facilities, quarterly quality bonus of up to 15% of fee revenue linked to score on facility-wide quality assessment

25. INCREASES IN FP UTILIZATION FOLLOWING INTRODUCTION OF A PBI PILOT IN GITEGA PROVINCE, BURUNDI Source: Busogoro and Beith (2010)

26. Initial results and lessons • PBI can generate significant increases in curative care visits, immunization coverage, family planning utilization, and institutional deliveries (in Gitega average 50-60% increase) • Increased productivity and efficiency (same staff produce more services) • Improved health center management: all develop business plans on which contracts are based, all monitor service statistics • Strengthened health management information system • Increased community involvement

27. Pakistan (D.G. Khan): Vouchers for reproductive health services delivered by a social franchise • Demand side: Poor women are sold vouchers (highly subsidized) which entitles them to: • FP, antenatal care, delivery, postnatal care from accredited Goodlife network providers • Transportation subsidy provided by provider when services are accessed • Supply side: Private providers in the Goodlife network receive: • Training • Benefit from demand generation from marketing and voucher reimbursements

28. Pakistan “Snapshot” FP Services as part of a maternal health package delivered through a social franchise in Pakistan FP Indicators: Vouchers redeemed for post delivery FP counseling Recipients: Voucher holder (woman) and service provider FP-linked payment mechanism: Voucher holder receives free services and transport subsidies; service provide receives a fee for providing FP counseling

29. Family Planning results among voucher clients (n=1569)

30. Lessons from Pakistan voucher program • Challenge to ensure enough demand to maintain provider interest in participating • Quality of care by providers varies--need strategy to assure quality care • Challenge to manage a growing network. Must consider a plan for large-scale administration and support • Payment must be timely--especially if providers advance payment for transportation • Consider adding a “completion bonus” if a voucher recipient receives all services - to provide incentives to providers for outreach and follow up

31. The bottom line... Family Planning can be incorporated into PBI schemes in ways that protect voluntary choice and are in compliance with US FP requirements

32. Thank you For more information: www.rbfhealth.org www.HealthSystems2020.org/section/topics/p4p