Performance-Based Financing (PBF) has too often been depicted as a package uniformly designed or implemented across settings. This is misleading. In this blog post, I present the evolution which has taken place in Tanzania.
Over the last decade, PBF has gained momentum in low- and middle-income countries (LMICs) as a health financing innovation to improve health system performance. It is agreed today that PBF is a reform package including not only financial incentives, but also enhanced autonomy, supervision, data verification, community involvement, and enhanced information system. This richness of ‘components’ suggests that we have to be very careful with simplifications of presenting PBF as one standard intervention which is uniformly designed or implemented across settings.
While adhering to some principles of autonomy and separation of functions, PBF schemes present some variations in design, implementation models, and settings, which inevitably leads to substantial heterogeneity in PBF programmes and eventually effects. Yet, to date, There are still publications providing few details on PBF variations – especially the design features – reinforcing the false view of PBF as a uniform intervention across settings. Some scholars have specifically highlighted the importance of design in the evaluation of PBF. Thus, there is a welcomed move in the scientific community as for the best way to evaluate PBF interventions. Instead of assessing whether PBF works or not, we should understand what works (in terms of design), why, for whom and in what context. The later understanding may need a theory-driven evaluation, by documenting the influence of design, context, and implementation process.
In this blog post, I present some reflections on the PBF design features in Tanzania. I will focus specific on how design features of PBF have evolved from pilot phase to national rollout in Tanzania. This is an aspect often ignored in PBF literature, while in fact incorporates a set of key explanatory factors of PBF effects. Thus, my reflections on how PBF design evolved in Tanzania will account the following questions: – what is incentivised? who is incentivised? what is the payment system? what are the institutional arrangements? what are the enrolment criteria?
The PBF experience in Tanzania
In early 2011, Tanzania decided to pilot the Pay-for-Perfornance (P4P) scheme in Pwani region which links providers’ reward and performance. The aim was to accelerate progress on the Millennium Development Goals 4 and 5, and to inform the national rollout programme. The pilot was funded by the Government of Norway, while Clinton Health Access Initiative supported the implementation together with the Ministry of Health. Broad Branch Associates were contracted to support the pilot design process.
The Pwani pilot evaluation has been very well documented. Studies revealed a significant positive effect of P4P on two out of eight incentivised indicators (institutional delivery and uptake of antimalarial during antenatal care). However, there was a number of process changes such as increased availability of drugs and supplies, increased supportive supervision, reduced chance of paying user fees, and greater provider kindness during delivery care. The costs of managing a P4P pilot were also substantial and exceeded the incentive payments.
In 2013, the best practices of the P4P pilot were discussed and a Task Force was created to oversee the transition from pilot to national rollout. From 2015, the Government of Tanzania with financial support from the World Bank and USAID embarked on another pilot in Shinyanga region (2015 -2016) before phase one of national rollout (2016-2020). It was a move from project-based P4P to a national RBF system for improving health system and accelerate the move to UHC. Phase one of national rollout (2016-2020) covered 9 regions selected mainly due to poor health outcomes and high poverty index. The evaluation of the rollout programme is currently undertaken by Ifakara Health Institute, London School of Hygiene and Tropical Medicine, and Chr. Michelsen Institute, and the findings are expected towards the end of this year.
How programme designs have evolved from pilot to rollout?
P4P programme in Tanzania was re-designed prior to rollout, and was rebranded as Results-Based Financing (RBF) national system. The re-designing process took into consideration the experience and lessons learned from the two pilots and from other settings. The following are key design elements that have changed from P4P pilot (2011-2015) to national RBF programme (2016-2020) in Tanzania:
- Provider payment method. P4P pilot paid providers using a single threshold (absolute coverage target) and multiple thresholds based on baseline performance / previous cycle (relative change). These approaches were constrained with difficulties of accurately measuring the catchment population when estimating service coverage. So, the RBF system is paying per service (case-based payment) conditional on quality scores as commonly done in many settings implementing PBF.
- Payment frequency.The pilot scheme paid provider after each cycle of 6-months, while the RBF programme pays on quarterly basis. The decision to increase the payment frequency may contribute to strengthen the incentive by influencing positive provider behaviour.
- Provider type. In the pilot phase, all eligible facilities (offering maternal and child health services) irrespective of level of care and ownership participated in P4P. This included private and faith-based facilities. The national RBF system, however, is focusing exclusively on public facilities only to align well with public administrative system. It is a challenge for government officials to oversee private facilities. In the pilot phase, for example, the autonomy to use P4P funds was limited in faith-based facilities as they relied on what the diocese would decide.
- Enrolment and initial start-up grant. Different from P4P pilot, a facility readiness assessment in terms of staffing, infrastructure, equipment, and waste management was conducted and rated facilities in terms of stars before enrolling into RBF. Note that the star rating program was the national initiative to improve facility quality and independent from the RBF program. However, using the star rating data for enrolment into RBF reflects how RBF can nicely integrate with other policy mechanisms. The minimum readiness criterion to enroll into RBF was to have one star with adequate staffing (at least one skilled personal at a dispensary level). All public facilities in the implementing regions received an investment grant of 10 million Tanzanian shillings each for facility improvement. Facilities with zero star required to improve and request for a re-assessment within one quarter. The aim was to ensure each facility has a capacity to perform before implementing RBF, and this has the potential to reduce payout inequality.
- Payment spending. Payments in the pilot scheme included 75% (90% for hospitals) as a share of staff incentive bonus, and the remaining share was for facility improvement. Since RBF programme was meant to reflect system change, a larger share of RBF payments (75%) are earmarked for facility improvement, and the remaining for staff incentive. So, the distribution of payments was reversed. This aligns well with the Government priorities of ensuring greater investment on structural quality of care, following a national readiness assessment (i.e. star rating) of facilities which shows some facilities had zero star in structural quality. The 25% share for staff bonus is also distributed between staff based on attendance point (to reduce absenteeism) and responsibility point (maintaining seniority of staff).
- Incentivised agents. P4P pilot incentivised only health workers at the facility level and health managers at the district and regional level. RBF programme expanded the range of beneficiaries by incentivising health workers, district and regional health managers, community health workers (CHWs), and zonal units for Medical Store Departments (MSD) responsible for the supply chain of medical commodities. This expansion reflects a system reform as opposed to project-focused programme.
- Number of indicators. RBF programme increased the number of incentivised indicators. While P4P pilot included 8 quantitative indicators for facilities and 4 for health managers, RBF programme includes 14 quantitative indicators for health centres and dispensaries, 6 for district hospitals, 3 for CHWs, 11 for health managers, and 4-5 for MSD units. RBF programme also includes quality indicators –which are measured through a quality checklist. Facility indicators for the pilot focused only on maternal and child health services, while the RBF programme incorporated the outpatient care and quality of care indicators. This was partly because of decreased utilisation of outpatient services in P4P pilot especially in lower level facilities (i.e. dispensaries) –which reflected a concern of worsening the non-incentivised indicators. The 3 CHW indicators include household visits, escorting pregnant women for delivery, and reporting maternal and perinatal deaths in the community. The pilot evaluation highlighted providers’ concern of limited influence in the community to stimulate demand. The 4-5 MSD indicators intends to ensure smooth and timely supply chain, since providers in the pilot phase complained about the unpredictable supply of medical commodities which affected their performance.
- Institutional arrangement. Types of key actors and their roles have changed from pilot to national RBF system to ensure separation of functions and integration of RBF system into the existing health system. P4P pilot relied much on a Pilot Management Team (including staff from Ministry of Health and Clinton Health Access Initiative, and National Health Insurance Fund as fund holder who disbursed fund after permission from verifiers). In contrast, RBF system include actors like Ministry of Health (regulator), Ministry responsible for Regional and Local government (facilitator), Ministry of Finance (fund holder), National Health Insurance Fund (purchaser) as well as internal verifiers (at regional level) and external verifiers (at national level). The integration and use of existing institutional set up help to reduce implementation costs and can potentially improve efficiency.
And it will keep evolving...
At this end, PBF in Tanzania has evolved towards integrating the initiative into existing health system and institutional set up, and integrating with other national policy mechanisms. PBF design in Tanzania is based on local context and priorities (e.g. on indicators, investment grant, spending guideline and incentivising CHWs and MSD), but also account for lessons learned from earlier pilots and from other PBF implementing countries. Some drivers of the evolution include a political will and the result of the interactions between different ministries and a large set of aid actors. Consequently, the RBF implementation in Tanzania has stimulated some reforms on provider payment mechanism toward strategic purchasing for Universal Health Coverage (e.g. the Direct Health Facility Financing of Health Basket Fund to frontline service providers). Thus, PBF designs are not static but they evolve over time even within a given country, and designing PBF based on context/local needs and priorities is key for success especially for integrating into health system. Just with any health financing policy, let's embrace this dynamism in our approach to PBF.