From very early on, PBF was also introduced as a quality improvement strategy. When it comes to improving quality, however, the theory of change is more complex, because the channels are multiple and potentially contradictory. Without being exhaustive, here are some important elements.
Paying for volume already has an influence on quality...
A first channel is the 'resources' effect. PBF will inject financial resources into the health facility. With these resources, the manager can make many decisions to strengthen the quality of care or services. For example, he/she may recruit more qualified staff; he/she can also improve the quality of the service (eg transforming a consultancy room to protect the privacy of users). It is my conviction that such improvements happen spontaneously in many health facilities under PBF.
Another channel stems from the fact that certain quality elements are determinants of quantitative performance. By remunerating the latter, staff are also indirectly encouraged to improve these quality elements. For instance, a health center keen on vaccinating more children will try to avoid stock-outs of vaccines; in its desire to attract more users, it will modify its opening hours ... or as it was, with a refreshing honesty, reported to us by a Rwandan nurse during a qualitative study in 2004: "From now on, we smile at our patients ".
But there are also elements of quality of care that are not determinants of volume. This is particularly the case for all quality elements that are not observable by the user (eg sterility of the surgical material) or which are ignored by the staff. A nurse who, due to lack of training, makes a diagnostic mistake in a systematic way will a priori continue to do so, regardless of the number of patients in consultation. Finally, there are situations of perverse incentives where quantity comes at the expense of quality. This is the case of the nurse who, to increase his quantity bonus, rushes through his consultation.
One can then wonder what effect purchasing quantity has on quality. The truth is that we don’t really know. One can suspect that some quality elements are improving – this is probably true for the aspects of quality noticed by the users. But one cannot exclude that on other aspects, quality suffers.
A solution: the introduction of quality checklists
To address this problem, PBF systems quickly introduced quality checklists into the payment system. Those who were in Rwanda at the very beginning of the PBF scheme will remember that this introduction was not straightforward: we discussed it thoroughly (among PBF experts).
The arguments in favor of these checklists were: "As a buyer, I do not want to buy only quantity; I want to make sure that every service I buy is of quality"; "By paying only for the quantity, there is a risk of incentivizing the health facilities to boost their volume, at the expense of quality"; "By paying for quality, we send the signal to the health staff that quality is important".
Arguments raised against these grids were: "Quality is multidimensional; many important elements are difficult to measure; we risk to only incentivize among staff what is easily measurable"; "Many determinants of quality arise from deeper causes, such as the initial training of health care workers; PBF does not address these causes".
As is often the case, there was some truth in both visions. In many countries adopting PBF, the initial level of quality is often very low - it is then relevant to create incentives for the presence of basic equipment and compliance with essential rules. You need an autoclave to sterilize surgical instruments. All health facilities must have clean toilets. Etc. PBF systems thus developed long lists of indicators with a focus on the availability of equipment and inputs. Routine data have shown almost everywhere that health facilities are sensitive to these incentives and that the quality index improves over time.
But those who were concerned about the bias in the measure of quality were also right. Those among you who attended our conference in Dar-es-Salaam will recall the presentation of a review of the lists of quality indicators in PBF systems. It showed that the indicator grids are biased towards what is easily measurable - equipment (hardware, etc.) (this study has now been published here).
The PBF quality checklists ignore important determinants of quality of care (eg knowledge of health personnel) and do not attempt to measure the outcome of the health services (e.g. cure). There is therefore a real risk that what is captured by the quarterly reviews is not enough to guarantee a level of quality that generates health benefits. In short, it is important for the nurse to have a stethoscope and medication, but if he does not know how to do a quality pediatric consultation and neglects to check some key parameters, there is a high risk that the diagnosis will be erroneous or incomplete.
This poses problems of different kinds. But for the sake of brevity, let’s just say that we could end up with a result contrary to our ambition: higher coverage rates, but mortality rates that do not move, simply because the quality of services is too low.
The battle for quality care is also our responsibility
Questions abound. Have we used all the power of PBF to improve the quality of care? Or, on the contrary, do we not overestimate the contribution that PBF can make? What are the right mechanisms to change the behavior of clinicians? What is measurable and sensitive to an incentive system? How do we boost synergies between PBF and other strategies to improve quality of care (quality assurance circles, accreditation, etc.)?
These and many other questions should be on the agenda. Some of the questions go beyond the PBF community, clearly. Currently, the whole international health community is concerned about the quality of care problem. A special commission has just been set up by The Lancet Global Health.
However, on the PBF CoP side, we must also do our fair share in this global learning program. To this end, our CoP will launch a series of activities in 2017. We will proceed step by step as we obviously need to take into account our organizational capacities and resources when investing in this agenda (if you are a possible sponsor, do not hesitate to contact us!).
Our attention should focus on two points. On the one hand, we must reopen the reflection on the theories of change of PBF. The mechanisms set in motion by PBF are quite complex, much more so than what has been said so far about this. The question of the theories of change is key, also for other purposes, but is particularly important for the issue of quality of care. We have already discussed this point in Dar-es-Salaam; we must now move into high gear. Expect some blogs and articles in the coming weeks and months.
On the other hand, we must also reflect on the quality indicators currently being collected in PBF systems. The time for critical analysis has come. This second project is ambitious (and as long as some checklists, perhaps!) - so we will take it step by step. As a first step, we decided to focus on quality indicators of family planning services. This challenge has the advantage of being well confined. It is also an area in which quality work has already been produced by different groups. Concretely, we have decided to organize an international meeting to which we will invite both family planning experts and PBF experts. Together, they will review existing indicators, identify areas for improvement, and formulate an implementation research agenda.
To support this process, we are currently looking for experts from both disciplines. We have already created a project on our Collectivity platform. The first responsibility for the volunteers will be to help us organize this meeting of experts. If you want to give us a hand, this is the time to apply! The meeting is scheduled for late summer and will take place in the beautiful city of Antwerp. Hope to see you there.