Pay-for-performance, Motivation and final output in the health sector in DRC

In Haut-Katanga district, the 96 health areas (totalizing 152 health facilities and a catchment population close to two millions) were randomly assigned to one of two payment systems.
- In the fixed payment group, the amount allocated to each facility was calculated based on the staff in the facility: a list of eligible workers was established at the beginning of the pilot conjointly by Ministry of Health; each worker received a given payment depending on his/her grade and experience.
- In contrast, payments to the PBF health facilities were to be made after verification of declared service volumes by facilities. The targeted services included seven services at the primary care level (outpatient first curative consultations, prenatal consultations, deliveries, obstetric referral, children completely vaccinated, tetanus toxoid vaccination, and family planning consultations) and three additional services at the secondary care level (C-section, blood transfusion, and obstetric referrals to hospitals).
In order to ensure neutrality in the level of financing between the two groups and isolate the incentive effect from the resource effect, the total budget allocated to health facilities in the PBF group was the same as the total budget allocated to health facilities in the fixed payment group. The relative prices attached to the targeted services were constant, but absolute prices and facility payments were determined by the quantity of services provided by the facility relative to the quantity of services provided by the other incentivized health facilities in order to keep the total enveloppe constant. The budget used in this experiment estimated at $0.43 per capita per year.
Service volumes were measured by use of monthly reports submitted by facilities, in which the number of patients for each targeted service was reported. Subsequently verification of declared service volumes was conducted by verification agents through (i) comparing reported volumes with those found in health facility registers, and (ii) verifying that the information noted in the registers was true by conducting community verification: a random sample of 30 patients in registers were selected and visited by independent associations to check the accuracy of the information reported in the facility register. Community verifications were meant to take place only in the PBF group as part of the financing mechanism. However, we conducted community verifications in the fixed payment health facilities for impact evaluation purposes (1 community verification by facility in the comparison group). The fixed payment health facilities had no incentive to cheat on service volumes so the comparison of discrepancy rates between the PBF and the fixed payment groups allow for differentiating cheating from natural -unavoidable- discrepancies due to the fact that some patients moved or were absent at the time of the verification. A system of financial sanctions was integrated in order to reduce providers’ incentives to submit fraudulent reports and over-reporting of phantom patients.

2010-06-01

2012-12-01

User Fees

Accessibility of Health Services : opening hours, worker attendance, on-the-job effort, number and qualification of workers, number of service varieties offered, number of preventive sessions organized at the facility and number of outreach activities in the community in the last 12 months, waiting time before the consultation.

Service Quality: consultation time, compliance with standard medical procedures, proportion of patients who understand the diagnosis and prescriptions, proportion of patients and household members who are satisfied with the visit.

Service Utilization in the last 12 months: proportion of individuals who visited a health facility, who got sick but did not visit, proportion of children aged 0-5 who took at least one immunization shot, the number of immunization shots reported in the immunization card, and the proportion of children who have a scar from TB immunization on the shoulder, proportion of attended deliveries among mothers who gave birth in the last 12 months, proportion of C-sections, number of prenatal and postnatal visits at the facility, proportion of mothers supplemented with iron and taking malaria preventives, number of months mothers breastfeed their newborn, proportion of women and partners who are in favor of the use of family planning, proportion of women actually using family planning, number of patients in the last month as reported by the facility head.

Population Health Status: under-5 weight-for-height z-score, number of persons who died in the last 12 months in the household, and among them the number of women who died for perinatal reasons and the number of children under 5, proportion of new-born in the last 12 months that are still alive.

Health Facility Revenue

Health workers’ satisfaction, anxiety and motivation

96 health areas were randomly assigned to one of two payment systems.

Public lottery

Health area.

Yes

96 health areas

152 health facilities, 331 health workers, 1014 patients and 1704 households

48 health area control, 48 health area treatment