Performance payments will be made to health service providers and health administration units contracted in the target areas. Public, quasi-public and private health facilities, including health centers and first level referral hospitals, will be targeted in rural and urban areas. The purchasing, verification, community mobilization and coaching will be organized through provincial purchasing agencies (EUPs: Etablissement d’utilité publique). PBF payments will be paid to these health facilities in proportion to, and in payment for, achieved quantity and quality results. Facility payments will be based on (i) the quantity of services defined through a package of basic and complementary activities delivered to the targeted population, and (ii) the technical quality of these services as measured through comprehensive quantified quality checklists. Facility payments will be made quarterly after service volumes have been verified and quality of technical support and care has been assessed and certified by the EUPs, and validated through special governing boards at the provincial level. After the quantity and quality of services provided are certified, payment will be released to contracted health facilities via fundholding arrangements.
Modified quality checklists (quality incentives): An innovative aspect of the PBF approach in DRC will involve the content of the quality checklist that will be used for assessing the quality of care in health centers and hospitals. The amount of money paid for the quantity of services can be increased by up to 25% according to the quarterly quality score, if the facility exceeds the threshold score of 50%. In addition to determining the payment amount to facilities, the quality checklist also provides guidelines for good practice and structures the supervision of the facilities by the staff of the health zones. The study will evaluate the use of different types of quality checklists at different sets of health facilities. All checklists will include measure of structural quality, process and content of care. Examples of measures of structural quality are: proper storage of drugs, cleanliness of the facility and existence of required registries and protocols. Measures of process and content of care include indicators such as correct entries into registries and medical records and checking these records for proper application of the protocols. In selected health facilities, ‘Vignettes Quality Checklist’ will also include healthcare providers’ responses to clinical vignettes as indicators of quality of care. The vignettes will cover cases that represent the most common causes of morbidity and mortality and will be repeated each quarter. It is theorized that the quarterly repetition of these cases will reinforce the protocol related to these common cases. However, these measures are also a limited in representing quality of care as there might be a gap between what providers know and do when they are actually treating the patients.