This guest blog was written by Lindsay Morgan of Health Systems 20/20, Broad Branch Associates.
A shift is taking place in the global health community. Pay for performance (P4P), an umbrella term for any program that transfers money or material goods conditioned on taking a measurable action or achieving a predetermined target, has been gaining currency in policy circles for years (Rena Eichler and Ruth Levine, eds., Performance Incentives for Health: Potentials and Pitfalls, Center for Global Development, 2009). But the conversation is changing.
“Questions no longer center on why (whether or not P4P should be tried),” said Rena Eichler in her opening remarks at a Global Health Council brownbag on P4P, “but rather on how programs actually work on the ground.”
Eichler, the president of Broad Branch Associates (BBA), a leader in P4P and partner on USAID’s Health Systems 20/20 project which is providing technical assistance (TA) to countries to design and implement P4P schemes, moderated the brownbag on April 28, 2011, which brought together representatives from the World Health Organization, the World Bank and various academic and research organizations to discuss lessons and challenges in implementing P4P programs in three sub-Saharan African countries.
As well as providing incentives, P4P aims to enable individuals to act on their intrinsic motivation by providing, for example, increased supervision, support and empowerment to health facilities and managers. Where P4P is being tried, the evidence strongly suggests it can have a significant and rapid effect on utilization of essential health services.
The Democratic Republic of Congo (DRC), Senegal and Mozambique are at different stages of program development, and the genesis of the concept also differs between countries.
The DRC has some of the earliest experiences with P4P in sub-Saharan Africa. As Natasha Hsi, a program manager with Health Systems 20/20, explained, the P4P landscape in the DRC has been chaotic, with a plethora of donors implementing their own schemes in different parts of the country — some of which date back nearly a decade. Until recently, there was little coordination with the ministry of health, but that is changing: P4P has been incorporated into the MOH’s application for a Round 9 Global Fund grant, which is providing an opportunity for the MOH to take the reins of P4P.
In Mozambique, which is still in the early stages of design, the impetus for P4P originated with the donors, who were keen to see more bang for their development bucks. The MOH, however, is engaged in the design process and, according to Catherine Connor of Abt Associates and deputy director of the Health Systems 20/20 project, “they are asking all the right questions: Who will sustain this? Will increased volume hurt quality? Will individual incentives harm teamwork and equity? This is a country that is cautious and we are respecting that caution.”
By contrast, in Senegal, whose P4P pilot will launch this summer, interest in the concept came after the MOH visited Rwanda, in a trip to understand fiscal management in the health sector, and was impressed with the P4P reform. Desire to improve health results and inspiration from the Rwanda trip led the MOH to seek help to design its own program.
The presentation sparked several questions.
Q: Does rewarding certain services lead to a neglect of other important services?
Connor said this is indeed a risk, but it is mitigated by insisting that health facilities monitor all indicators, not only those linked to incentive payments. Alex Ergo, senior health economist with BBA, said that the same will be done in Senegal. Moreover, P4P is not a static system: “It is a process of revision,” he said. Though gaming the system is always possible, P4P programs, including the one in Senegal, are establishing robust verification mechanisms to detect cheating, with penalties for those caught.
Q: What’s the role of community health workers?
In Senegal, community health workers are among those health workers eligible to receive an incentive, among other cadres, including lab technicians, and even cleaners.
Q: How will P4P programs be sustained when donor funding dries up?
Connor said that P4P can simply become a new and better way for donors to channel development assistance in many low-income countries where it is likely that donors will remain engaged for the next 15-20 years, as long as there is commitment from the government. Eichler noted that the cost of incentives is relatively small in most P4P programs. “The big money is in setting up the systems and the TA,” she said. “It is not hard to imagine a country shifting some of their own funding for incentives if there is an appetite for P4P and evidence that it can make a difference.” Ergo also added that engaging a wide range of stakeholders beyond the ministry of health and channeling money through existing national systems (such as health insurance schemes) are critical for generating buy-in for the concept and ensuring sustainability.
Q: Will P4P succeed when health systems in so many countries remain dysfunctional?
“P4P is not a magic bullet,” said Ergo. “It’s only part of the solution. It helps to strengthen parts of the health system that have not been well addressed in the past. The hope is that it can bring in dynamic that may help improve things over time.”
With P4P programs in over 20 sub-Saharan African countries, there will be many experiences to learn from in the years ahead.