Performance - based Contracting for Health Service Delivery in Uganda

1. Performance - based Contracting for Health Service Delivery in Uganda Flagship Course: Result Based Financing Kigali, June 29, 2010 Peter Okwero

2. Outline of presentation • Background - PNFPs • Background – Performance Based Contracting • Experimental design, method and sample • Results • Conclusion

3. Background • Private not-for-profit (PNFP) sector provide about of curative care; • The PNFPs are coordinated through 3 Medical Bureaus • The PNFP receive government subventions supposedly under a “Memorandum of Understanding” with the relevant district;

4. Contracting in Uganda • The key question was on how to strengthen the MoU to monitor performance of the PNFP Recipients; • The 2003 Joint Review Mission mandated the Bank to conduct a prospective quasi experimental study to determine whether PNFPs would respond positively to the introduction of performance based contracting for health service provision.

5. Experimental Design - 1 • Conducted by the Institute of Public Health • Addendum to the MoU - Six performance targets, of which the facility can choose three: • Increase OPD by 10% • Increase attended births by 5% • Increase number of children immunized by 10% • Increase modern family planning use by 5% • Increase number of antenatal visits by 10% • Increase treatment of malaria among children by 10%

6. Experimental Design - 2 • Criteria for Performance Bonus Payments: • 1% of base grant for each target met in each 6-month period • 1% of base grant for each target met by end of year • 1% if two targets are met by end of year • 1% if three targets are met by end of year • Total possible bonus payments for the year = 11% (3+3+3+1+1)

7. Experimental Design - 3 • Random assignment of facilities to cells Sample of facilities Group A: performance-related bonuses Group C (control): no changes Group B: freedom to spend resources as it desires

8. Experimental Design: Sample -1 • Five districts; • Stratified by region and administrative capacity – High, Moderateand Low; • Twice-yearly surveys (Facility, Staff, Exit Poll, HH).

9. Arua Jinja Kyenjojo Mukono Bushenyi

10. Experimental Design: Sample- 2 • Random assignment of 118 Health Facilities: • 22 PNFP facilities in group A (performance bonus) • 23 PNFP facilities in group B (freedom to allocate) • 23 PNFP facilities in group C (control group) • 26 Private for-profit facilities (in control group) • 26 Public facilities (in control group)

11. Selection of Performance Criteria

12. Results: Targets Reached

13. Results: Average Bonus Paid

14. Performance Targets Reached by Wave

15. Performance Bonuses Received by Wave (Median)

16. Total Outpatient Visits –Performance group did not outperform other groups

17. Immunization -Performance group did not outperform other groups

18. Double Difference Method: D-in-D tests, group A

19. D-in-D tests, group A

20. D-in-D tests, Group B

21. Conclusions • Performance bonus didn’t outperform other groups • Perhaps the bonuses were not large enough; • Bonuses were paid to the facility and not providers; • Complexity of the performance-based contract; • Did the experiment take long enough to take effect; • Changing priorities. • Facilities allocate budgets more effectively than the Ministry of Health. • Remove restrictions on base grant.