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Performance Based Financing and Quality of Care: ready for an upgrade?

3/20/2017

31 Commentaires

 
Bruno Meessen
Performance Based Financing (PBF) is now being implemented in a large number of countries. Ensuring that the PBF strategy is continuously improved must get our full attention. In this blog post, I focus on the challenge of quality care. I also present what the Community of Practice intends to do on this key issue. We are currently looking for experts willing to help us organize a first international meeting. Why not you ?
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The fact that PBF aims to increase the production of health services in countries where services are largely underutilized, is well known. It is also easy to understand the logic: if you are paid according to the number of units you produce, as long as your marginal cost of production is lower than the price you are paid, you have an incentive to increase your production.

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.
31 Commentaires
BIRINDABAGABO Pascal
3/22/2017 07:21:12 am

Dear Prof Bruno,
Thanks so much for the above blog My self, it has really expended my knowledge on what PBF can address with regards to quality in healthcare is concerned. In Rwanda, The Ministry of Health and MSH started on how to review the PBF Framework and propose a sustainability plan... We had just resumed a workshop with different stakeholders, mainly implementer (community and facility based PBF). I hope that some of your reflection from this blog will help in future while considering the PBF sustainability plan but also how to consider the effect of externals factors (Nursing education system) for only consider that as an example, on the healthcare delivery... Or to know clearly what PBF can and what it can't solve out. Thanks so much for that!!!!

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Comment j'ai récupéré mon ex-mari...........

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11/27/2024 03:09:28 pm

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1/27/2025 11:07:47 pm

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2/13/2025 04:01:08 pm

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Edita Reinders
3/2/2025 11:27:47 pm

Mon mariage de plusieurs années a été rempli d'une misère sans fin qui a conduit au divorce que je n'ai jamais voulu avec mon mari. Tout s'est effondré et nous nous sommes séparés. J'ai essayé de passer à autre chose mais c'était si difficile pour moi parce que j'aimais toujours mon mari et ma fille a toujours pleuré parce que son père lui manque. Je n'avais pas d'autre choix que de chercher de l'aide, ce qui m'a conduit à contacter le DR Ilekhojie. Après avoir vu tant de bonnes remarques sur son travail et l'avoir contacté, il m'a assuré de nous réconcilier avec mon mari grâce à son rituel de réconciliation. Il m'a expliqué que mon mari allait changer d'avis sur le divorce et revenir et que nous serions à nouveau une famille heureuse. Je suis heureux de vous dire que l'amour et le bonheur ont été rétablis et que nous nous sommes remis ensemble grâce au Dr Ilekhojie. Il n'est jamais trop occupé pour aider qui que ce soit. Alors contactez-le maintenant si vous avez également besoin d'aide. E-mail : [email protected] ou envoyez-lui simplement un SMS via WhatsApp au +2348147400259

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3/4/2025 04:27:28 pm

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Edward
3/18/2025 05:06:44 pm

It was a great joy having my wife back again after been separated for four years without a word than divorce which she always wanted and I refuse then she left, I was browsing through the internet when I came across a good review about Dr Ogudugu, I made a contact with him and followed his instructions he assured me within 48 hours my wife will come back home, just like a surprise as he said within 24 to 48hours my wife drove down to my house pleading for we to reconcile and start over again in love and harmony. I strongly recommend Dr Ogudugu to anyone with relationships/marriage problems or depression contact Dr Ogudugu call/WhatsApp +2348163026536, Email: [email protected].

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Jenny Savage
3/29/2025 09:23:01 pm

I am so happy to share this fantastic testimony of mine. My life has changed round completely in 48hours. I can see myself in the mirror and smile. I have confidence in myself and my abilities for the first time in ages. I have my boyfriend back in my life with the help of Dr Osofo. He said sorry 24 hours after the spell was created. He said he realised that he never really wanted to break up and he could not handle emotional baggage I was carrying around all the time. He said that he thought he was the negative influence on my life and thought it best to leave. He said it was hard that I kept talking about the past all the time. We have both forgiven each other. I have money in my pocket that is my own at last. (My compensation cheque came through. I was told it was months away. I am living proof of what Dr Osofo can do. I thank you so much Dr Osofo for the wonderful thing you did in my relationship. I am so happy now. With your help we were both able to see and speak the truth to each other. I never thought a spell could help a couple before. I am very pleased to contact you and initiate all this to happen. Anyone who has a relationship problem can contact Dr Osofo via email. ( [email protected] )
his whatsAPP +2349065749952

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ross
3/29/2025 09:38:36 pm

I thought the physicians says there is no cure for HSV 2!!! I am telling you today that DR. JALEKA cure HSV 2 with his herbal medicine and once you get cured you are cured forever it is never reversible, I have been suffering for this deadly disease called HSV 2 for more than 2years and I lost all hope because my doctor says there is no cure for HSV 2. Brethren I saw a testimony on the internet on how DR. JALEKA cure HSV, Hapatitis etc with his herbal medication and an email and whatsapp to him was also displayed, I thought this was a joke but I decided to contact him and he replied telling me not to worry that my problem is over . DR. JALEKA sent me a herbal medication to drink for one month. but only 2weeks I feel strange and I went to my doctor and he confirmed me negative. He can help you too. Contact him via WhatsApp +2349129412675. He is capable of curing AUTISM, HERPES, HPV, HSV1&2, HEPATITIS A B C, and DIABETES.

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Angel Castor
3/30/2025 03:36:48 pm

I'm Angel Castor from the US. White Caucasian Female. I'm 43 years old and I got married at the age of 25, I have only two children and I am living happily.

Five years ago, my husband's behavior became so strange that I didn't really understand what was going on. He packed out of the house to another woman’s house and I love him so much that I
never dream of losing him, I tried my best to make sure that my husband got back to me but all to no avail, I cried and cried seeking help. I discussed it with my best friend Alison and she told me she can help me. She told me of a man called Dr. Odunga, she told me he is a very great man and a real man that can be trusted and there is nothing concerning love and Pregnancy issues he cannot solve and she told me how he has helped her and countless number of people in

restoring their relationship. I quickly contacted his email address at [email protected] I explained all my problems to him, he told me that I should not worry that all my problems will be fine. Presently, I am very happy I got my husband back to me with the help of Dr. Odunga and we are living happily with so much love for each other. What-app message/call him at +2348167159012 to help you

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Vanessa Laime
4/1/2025 03:00:41 pm

Je n'aurais jamais cru que des gens puissent être aussi gentils, altruistes et extraordinaires avant que le Dr Ilekhojie ne m'aide. Mon mariage avec mon mari n'avait pas encore un an et nous avons commencé à avoir tant de problèmes. Mon mari m'a quittée en me jurant de ne jamais revenir. Je ne savais plus quoi faire de ma vie à ce moment-là. J'ai dû continuer à chercher de l'aide jusqu'à ce que le Dr Ilekhojie vienne à mon secours. Après avoir consulté, j'ai compris que l'ex de mon mari continuait à le manipuler spirituellement pour le récupérer. Le Dr Ilekhojie m'a expliqué tout ce qu'il fallait faire avec assurance, et je l'ai fait. Il m'a aidée et le résultat a été incroyable. Maintenant, mon mari est de retour et nous vivons dans la chaleur et le bonheur. Envoyez-lui un message sur WhatsApp au +2348147400259 ou à [email protected]

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Vesna Urma
4/8/2025 11:13:16 pm

J'ai eu une relation difficile avec mon mari par le passé, ce qui a conduit à un divorce. Le souvenir de mon mari était encore présent en moi et j'ai réalisé combien je l'aimais et combien il me manquait. J'ai pleuré amèrement cette nuit-là, pensant avoir perdu l'homme que j'aimais tant. J'ai demandé conseil et un ami m'a donné les coordonnées du Dr Ilekhojie. Je l'ai consulté car il a aidé de nombreuses personnes à se réconcilier. En seulement quatre jours, j'ai pu bénéficier d'une prière de réconciliation spirituelle avec lui et tout a changé pour de bon dans ma vie. Je vis à nouveau heureuse avec mon mari. Nous envisageons de renouveler nos vœux et de nous remarier. Je témoigne aujourd'hui que le Dr Ilekhojie est la solution à tous les problèmes de couple ou de mariage brisé. Contactez-le pour toute question. Whatsapp +2348147400259 ou par e-mail : [email protected]

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Heather Delaney
5/27/2025 05:25:38 am


It is amazing how quickly Dr. Excellent brought my husband back to me. My name is Heather Delaney. I married the love of my life Riley on 10/02/15 and we now have two beautiful girls Abby & Erin, who are conjoined twins, that were born 07/24/16. My husband left me and moved to be with another woman. I felt my life was over and my kids thought they would never see their father again. I tried to be strong just for the kids but I could not control the pains that tormented my heart, my heart was filled with sorrows and pains because I was really in love with my husband. I have tried many options but he did not come back, until i met a friend that directed me to Dr. Excellent a spell caster, who helped me to bring back my husband after 11hours. Me and my husband are living happily together again, This man is powerful, Contact Dr. Excellent for any kind of spiritual problems or any kind of spell or relationship problems, he is capable of making things right for you. Don't miss out on the opportunity to work with the best spell caster. Here his contact. Call/WhatsApp him at: +2348084273514 "Or email him at: [email protected] ,For more information visit his website:https://drexcellentspellcaster.godaddysites.com

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Athony Isak
6/6/2025 10:13:41 am

My heart is so filled with joy. If you are suffering from Erectile dysfunction or any other disease you can contact Dr. Moses Buba on this [email protected] or His website : https://www.facebook.com/profile.php?id=61559577240930 .website page https://bubaherbalmiraclem.wixsite.com/website
. For more information from me reach me via WhatsApp : +44 7375 301397

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