Paying Health Care Providers for Performance: Evidence from Rwanda

1. Paying Health Care Providers for Performance: Evidence from Rwanda Paul Gertler UC Berkeley January 2009

2. Collaboration • Research Team • Paulin Basinga, National University of Rwanda • Paul Gertler, UC Berkeley • Jennifer Sturdy, World Bank • Christel Vermeersch, World Bank • Policy Counterpart Team • Agnes Binagwaho, Rwanda Rwanda MOH • Agnes Soucat, World Bank

3. Overview • Background/Motivation • Rwanda • Program Description • Evaluation Design and Methodology • Baseline Descriptive Statistics • Impact of PBF • Next Steps

4. Context: Developing World • Africa • Very poor health status • Weak health care systems • Brain drain – doctors & nurses leaving • Massive AID could be wasted • World Wide (WDR 2004) • Low Quality of Care • Training/technology have had small effect on Quality • Provider absenteeism high & effort low

5. Pay For Performance • Pay Medical Providers a bonus based on performance measurement • Improve quality of care and outcomes • Improve job satisfaction & retention • Organization Challenges • Individuals versus team incentives • Measuring performance • Cheating/Misreporting

6. Rwanda: Central African Country • 9 million people • Genocide in early 1990s • GNP per capita: 250 US$ • Weak Health Care Infrastructure • 36 Hospitals, 369 health centers • Doctors: 1/50,000 inhabitants • Nurses: 1/3,900 inhabitants; • 17% of nurses in rural areas • Poor health status, but getting better

7. MDG 4: Infant and child mortality

8. Performance-based Financing (PBF) • Local Initiative • Objectives • Increase quantity & quality of health services provided • Increase health worker motivation • Financial incentives to providers to see more patients and provide higher quality of care • Increased resources • Financial incentives • Operates through contracts between • Government • Health facilities providing services

9. Quarterly Payment to Facility i in period t Pj = payment per unit of each PBF service j Uijt= number of patients using service j in facility i in period t Qit = facility i’s quality in period t

11. PBF Facility Quality Score Where Skit = facility i’s Quality index of Service k • Indicator types: • Structural: Availability of medical equipment/drugs needed to deliver adequate medical care • Process: Clinical content of care (CPGs)

13. PNC Quality Indicators

14. Monitoring Facility Reporting • District Comite de Pilotage • Approves quarterly payment • Based on facility reports & independent audits • Random utilization audit (once quarterly) • One focal point per administrative district • Random quality audits (once quarterly) • District supervisors based in District Hospital • Interview random sample of patients • Identify phantom patients • MSH study – less than 3-5% phantom patients

15. Evaluation Questions: Did PBF… • Increase the quantity of contracted health services delivered? • Improve the quality of contracted health services provided? • Improve child health status?

16. Identification Strategy • During decentralization, phased rollout at district level • Identified districts without complete PBF in 2005 • Group districts into “similar pairs” based on population density & livelihoods • Decentralization reallocated districts • Some new districts had PBF in an area of the new district • Gov’t rolled PBF to remaining clinics (treatments) • Districts matched to these partials controls • Others: randomly assign one to treatment and other to control • 8 pairs

18. Isolating the incentive effect • PBF • Performance incentives • Additional resources • Compensate control facilities with equal resources • Average of what treatments receive • Not linked to performance • Money allocated by the health center management

20. Sample • 165 health facilities • all rural health centers located in districts • 2145 households in catchment areas • Random sample of 14 per clinic • Panel data: 2006 and 2008

21. Survey Content • Health Facility Data • Financials and Human resources • Lab test, equipment and medicine availability • Provider interview for competency (vignette) • 8-10 patient exit Interviews for prenatal process quality • Household survey • Socio-economics • Utilization • Health outcomes

22. Health Facility Results • Did we isolate incentives effect? • Log expenditure between Tr and Phase II • Did randomization balance treatment/control groups? • Did utilization increase? • Did structural quality improve? • Did process quality improve? • Prenatal Care (PBF pays for this) • Child Curative Care (PBF does not pay for this)

23. Log Expenditures • Randomization balanced baseline • Follow-up balanced, so difference in follow-up outcomes due to incentives not resources

24. Baseline Balance • Utilization (PBF) • Structural Quality • Availability of staff, equipment & drugs needed to deliver care (PBF) • Little room to improve • Process Quality • Competency (Vignettes) • Process Quality (Patient exit survey)

25. Baseline Expenditures & Staffing

27. Prenatal Competency & Quality • Standardized vignette presented to provider • Unprompted responses for competency • Measure of ability/knowledge • Based on Rwandan Clinical Practice Guidelines • Process quality • Patient exit interview for process quality • Clinical content of care • Provider effort

28. Quality Conceptual Framework Production Possibility Frontier What They Do: (Quality) What They Know (Ability/Technology)

29. Returns to Training/Technology low (data from 12 countries) PPF What They Do Actual Performance Ability/Technology (More Training & Equip/Drugs )

30. Goal: Use Pay for Performance to Close Productivity Gap PPF What They Do Productivity Gap Conditional on Ability Actual Performance Ability/Technology

31. Prenatal Provider Competency & Quality

32. Impact of PBF: Statistical methods • Have balance at baseline on all key outcomes • Use difference in differences analysis • Not a pure randomized experiment • Clustered at district year level • Facility Fixed Effects • Year dummy • Controls: age, parity, education, household size, health insurance, land, value of assets

37. Baseline Prenatal Provider Competency & Quality

42. Impact on Child Height • 0-11 months = +0.28*** • 24-47 months = +0.86***

43. Results Summary • Balanced at baseline • Expenditures same, so isolate incentives • Impact on utilization • Delivery & Child prevention, but not prenatal • Impact on prenatal quality • Bigger for better doctors • Reduced child morbidity • Taller children

44. Policy