Will Performance-Based Financing survive Universal Health Coverage?

2/24/2012

Jurrien Toonen

In this blog post, Jurrien Toonen (KIT, Amsterdam) wonders how Performance-Based Financing will fit in the Universal Health Coverage agenda, which was the main focus of a major conference in Bangkok last month.

This year’s theme of the 20th Prince Mahidol Award Conference (PMAC) in Bangkok organized in January 2012 by the Thai Government, was: “Towards Universal Health Coverage (UHC) – health financing matters”. The conference included 48 sessions in 5 days – including one on P/RBF. With so much going on, it was impossible to attend it all, so I will limit myself to some general comments on UHC and what could be of interest for P/RBF in PMAC.

What is hot – and what’s not

Thailand is one of the success stories where UHC has been attained over the last 10 years. There was a high level of “UHC – yes we can” emotions, with UHC promoted as something that can be achieved by all countries. It gave the impression – which was acclaimed by several speakers – that we’ve moved on to the Rio agenda of “development” rather than poverty eradication, and that the MDGs have had their time in the spotlight.

Even Health System Strengthening seems no longer “hot” for some actors – as observed by Dr Hercot on the IHP blog (you can also access his post on the UHC-forward website that was launched by R4D that same week of the PMAC).

Even if UHC is hot now, there was still quite some discussion on what it is, and what it’s not. UHC may sound like the 1978 “Health for All” agenda of Alma Ata, but the strategy looks different this time around. According to the WHO definition, UHC focuses on making health care available for 100% of the population, increasing the health care package to essential care, while making it financially accessible. Yes, health financing matters, but many raised the issue that equity should be better anchored in UHC. Tim Evans from BRAC University defined UHC as “intolerance to inequities in health care – ending the injustice that too many have no access”. Also, UHC seems to be about providing health services only, with little regard for what we have learned the last decades that improving health outcomes does not depend on health services only but also on the socio-economic determinants of health (education, water and sanitation, nutrition, …). Little of this was discussed in Bangkok.

Will PBF still be hot in Universal Health Coverage?

Much of the discussions on UHC was about countries increasing their spending on health – which is a great thought but we know from experience that in many countries this has not and will not be possible. Thailand has proved that it is possible to attain UHC in a middle-income country, but a first question would be: can we in many other countries? Health insurance was much discussed in PMAC, as it holds the potential to raise additional resources for the sector – but also to provide social protection and increase financial accessibility. However, on health financing relatively little was heard about fostering cost containment by improving efficiency, combatting fraud and corruption, reallocation of existing resources, and increasing performance of human resources. Getting rid of the waste in the system is a good second best after (not) increasing a country’s spending on health.

If indeed UHC is here to replace last week’s fashion, the MDGs, would that be good or bad news for P/RBF? It may be that UHC will save P/RBF from its narrow MDG-focus (and therefore its perverse effects), but also that UHC will again put even more emphasis on the level where results are produced: at the operational level. The call for increased funding on health was loud in Bangkok, but UHC should not stop at increasing geographical and financial accessibility. Whether it be in the MDGs or UHC (or whatever comes next), we must remember the real challenge is in organizing services in health facilities in an efficient way so that patients will make use of them. Here P/RBF can play a key role. P/RBF has the potential to make services more cost-efficient, in order that health staff will be motivated to provide more “health for our buck” with existing (financial and human) resources. It may enable staff to tackle the bottlenecks that they know well, but cannot address because they are driven by input-based budget lines. So, P/RBF can play a very important role in UHC, but only if we make sure that impartial, sound and thorough evidence on P/RBF exists. This evidence is needed firstly to convince those who remain hesitant. In the P/RBF session, a literature study presented proved that evidence on P/RBF is “still thin”, and another (on P/RBF in OECD countries) that “P/RBF most often caused distortions”. Dr. Kutzin from the WHO even mentioned that the list of failures of P/RBF is longer than its list of successes. So, if we know from practice that it is working in many settings we must collect evidence to find what works (or works not!) and why, and use this evidence. But not only to convince donors – above all to strengthen the P/RBF approach. I urge you all to be courageous enough to challenge P/RBF beliefs and critically study them, to make sure that P/RBF will not be another donor fashion, that fades, leaving us looking again for the next-month flavor after Alma Ata, Bamako, WDR ’93, MDGs, and ……. UHC?

15 Commentaires

Gyuri Fritsche

2/26/2012 12:33:14 pm

Focus on money more of it….and not so much on how it is spent....this sounds like a merry-go-round.

Whether Universal Health Coverage will work in very poor countries, is one issue. We have one fine example (Rwanda’s community based health insurance scheme). Then again, Rwanda seems sometimes on the moon whilst everybody else is on Mars. The real problem is that for health insurance to work in very poor countries we have so few real world examples. The way health services are financed, managed and monitored is a much less abstract notion.

Getting more money to the frontlines in the form of Performance-Based Financing (PBF) which pays for services, conditional on quality seems a promising way forward. Two country health systems have scaled up such approaches (Rwanda and Burundi, in combination with other health system reforms), and an estimated 30 countries are currently designing and implementing PBF pilot schemes. The issue with PBF (and Jurrien lumps this with RBF- Results-Based Financing which illustrates this point), is that it is a combination of a fairly well defined set of health system interventions, whilst ‘RBF’ or ‘Pay-for-Performance/P4P’ is not. RBF/P4P is a mix of many different interventions both on the demand and supply side. This is also the reason why experts such as Dr Kutzin from WHO indicate that there is more proof that RBF does not work, than that RBF works.

A well-designed and implemented PBF intervention is a game changer. UHC and PBF: they could very well go together as whatever additional resources (through UHC or other means) are made available, PBF can use these funds where it makes a difference for the quantity and quality of health services: at the frontlines.

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Sophie Witter

2/27/2012 05:48:15 am

Hi Jurrien,

I fully agree with your analysis - UHC and PBF can be complements, if well crafted and implemented. Just to provide more background on the comment about evidence, the Cochrane systematic review on PBF in low and middle income has just been published - readers interested in this topic can find it at:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007899.pub2/abstract

Well done for driving this debate.

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SEMLALI

2/28/2012 04:14:39 am

Merci Jurien de ce partage précieux
Je crois que l'expérience du Thaïlande en matière de couverture universelle est unique, c'est vrai qu’actuellement la Thaïlande dispose d’un système de santé solide et crédible, mais à mon avis il est le fruit d’un travail extraordinaire effectué par des professionnels de santé à la hauteur de leur mission et aussi à l’image d’un engagement politique de haut niveau, la conférence annuelle sur une thématique de santé publique en est un exemple (PMAC).
A noter que le PMAC est organisé chaque année en mémoire du Prince Mahidol qui est le père de la médecine moderne en Thaïlande.
Regards

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Bruno Meessen

2/29/2012 02:42:30 am

Thanks Jurrien for launching this debate.

I agree with Gyuri that the confusion PBF / RBF / P4P is not helping. It is true that the World Bank RBF Program focuses on the MDGs 4 & 5, but this is mainly due to the orientation given by the sponsors of the Trust Fund. However, as you know, RBF and P4P can also be applied to many other health problems. For instance, in high-income countries, P4P was developed to improve the management of chronic diseases like diabetes. This is of course true also for PBF (cf the ongoing discussion on the google group on Non communicable disease indicators).

Has PBF, as it has been developed so far in sub-Saharan Africa, a narrow MDG focus? Maybe, but should one challenge such a focus? MDGs 4, 5 and 6 are very appropriate for the continent.

I am also a bit concerned by how UHC is understood by many experts. It is remarkable that when one reports on success with UHC, people mention Thailand, Rwanda, Ghana (to a less extent…). The implicit new equation is “UHC=health insurance”. To my mind, UHC does not imply a health insurance (but obviously one needs risk pooling). More fundamentally, UHC should include preventive services.

If leaders do not understand that the UHC agenda includes preventive services as well, we are heading towards a major shift of resources from cost-effective interventions benefiting in priority to the poorest and most vulnerable to less cost-effective interventions benefiting in priority to those able to afford curative services.

I am concerned. The UHC has a global dynamic. It is partly driven by the major problem of catastrophic health care expenditures in USA and Asia. I do not underestimate that problem (in 2003, referring to the reality of the latter continent, we coined the concept of ‘iatrogenic poverty’ - to highlight the fact that catastrophic health care expenditures are not only due to a lack of health insurance- providers have a clear responsibility), but we should contextualize the UHC agenda to African health priorities.

I do not mean that catastrophic health care expenditure is not a problem in Africa. I do not mean either that access is not a problem in Africa (in this respect, the MDGs have been pretty effective to mobilize leaders to remove financial barriers to priority curative services). I mean that I am concerned when I see so many African leaders willing to set up national health insurances in very short time span because they adhere to the UHC agenda. As public health technicians, our responsibility is to remind them that preventive services should be fully part of this agenda and still deserve their attention. The review done by Morris Kouamé on Senegalese candidates is informative in this respect. We are facing a new challenge.

UHC is a great goal and I guess that all of us subscribes to it. Our responsibility is to make sure that leaders understand well what UHC encompasses.

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Joe Kutzin

3/2/2012 10:20:33 am

When the topic and content of this blog post was brought to my attention, I was interested initially by the provocative title, and then by a statement attributed to me from the “RBF side session” at the PMAC in Bangkok. I was surprised by the statement because the core messages of the presentation I made were actually quite different from that implied by that statement. So just briefly on that, based on a discussion the other day with someone else who was at the PMAC session. Prior to my presentation, there was a report-back session based on a group work exercise. During that, participants listed, among other things, successes and failures with RBF/PBF experiences that they knew about. Later, someone (perhaps me, perhaps someone else) commented that the list of failures was longer than the list of successes. But whoever said that was only referring to the results of the group work exercise, so please don’t take it as a comment on the “global evidence” (just want to assure Gyuri Fritsche that I haven’t done any global review and really do not have an opinion on which way the balance of the evidence in pointing).

More importantly, though, I wanted to use the entry point given to me to summarize my perspective on the issue of Universal Coverage and Performance-Based Financing. I believe that without PBF, or more generally the strengthening of the purchasing function of health financing systems, progress towards UC cannot be sustained. Recall that in WHR2010 one of the main pathways to universal coverage was summarized by the phrase “more health for the money”. In effect, we were emphasizing the message that countries cannot simply spend their way to UC; there has to be a focus on improving efficiency throughout. And of course, one of the main ways that financing systems influence efficiency is through the purchasing function. This was really the core message of my talk in Bangkok (I’m happy to send to anyone who requests from me; write to me using the standard WHO email address). Just to summarize a few points from that talk here.

1st message: “RBF” (and yes, I don’t really distinguish between the nuances of the different acronyms such as RBF, PBF, P4P, etc.) should be seen as an entry point to strengthening the purchasing function of health financing systems, which in turn makes it very clearly part of the Universal Coverage agenda. In many countries and for many years, we have been recommending the importance of moving from passive to “active” or “strategic” purchasing. In its most generic sense, purchasing means the allocation of resources to providers. Strategic purchasing means using information on provider performance or population health needs to drive resource allocation. This is as compared to either historical, input-based line-item budgeting or completely unmanaged, untargeted fee-for-service. Thus, the initiatives bringing RBF, PBF, etc., into the policy arena offer a tremendous opportunity to strengthen and build national health financing systems. It is not merely the mechanisms, but from what I have seen in parts of the world where I have worked over the past decade (most notably in Kyrgyzstan and some east European countries), the process of implementing strategic purchasing itself builds capacity, as systems move away from historic inertia and become more data-driven. It can start a virtuous cycle of data generation, data analysis, raising questions, answering them, generating new questions, etc., etc. It is an intangible, but I have seen this process transform the culture of a health system.

2nd message: However, and related to the prior paragraph, this system-building objective needs to be an explicit part of the agenda. It is an example of a phrase I have used in reference to other aspects of health financing systems and initiatives: moving from scheme to system. Critically, this means that “projects” introducing these mechanisms need to focus on building/strengthening long-term capacity for the purchaser and the providers. This capacity dimension is not merely about training. There is no doubt that moving towards more strategic purchasing implies both a more functional information system and people with the skills to analyze and act on what the data are saying. It may be that in many countries, it is difficult to attract and retain the people with such skills in the core civil service, and hence part of the scheme-to-system agenda is also looking at the nature of the purchasing agency itself. A whole range of issues arise in this which are too long for this blog, but I just want to suggest that this be part of the “PBF agenda” if it is not already the case in countries.

My impression (and really, it is just that, as I have not looked at this systematically), is that there seems to be a lot of concern internationally about “pr

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Joe Kutzin

3/2/2012 10:22:28 am

[sorry, my contribution is too long and split in 2]

My impression (and really, it is just that, as I have not looked at this systematically), is that there seems to be a lot of concern internationally about “proving that RBF works”, but we don’t seem to acknowledge the counterfactual, which is the overwhelming evidence that historical, input-based line item budgeting does not do very much for efficiency, productivity, coverage, etc. I am not suggesting a wholesale change away from this, as it would no doubt be chaotic. But the introduction of “performance” (output, really) elements, blended with budgets, seems to be the direction in which to move. And certainly, this is what the higher income countries like the UK, France, etc., are doing in their primary care payment systems. So in this regard, RBF, PBF, etc. are not a unique low-income country innovation; it is a universal concept of interest to countries around the world. Given all of this, I would like to see some shift in the emphasis of donor agencies, from what sometimes looks like a kind of international research program of “proving it works”, to a more systematic effort to use the RBF/PBF initiatives to strengthen domestic health financing systems and capacities.
3rd message: despite my advocacy of the importance and potential for strengthening purchasing in health financing systems, it is not a panacea. There remain no “magic bullets” for reform. And on this topic in particular, economists like myself need to accept a dose of humility and understand that financial incentives are not everything. We are pretty good at measuring quantity and designing mechanisms to pay for it. But paying for “quality” is much more difficult, because for many interventions it is simply not possible to measure provider quality in a systematic, objective way. That is why so much of “Pay for Performance”, in countries at all levels of income, is really paying for reporting, or paying for processes that are very likely to be associated with good outcomes. Many people who look at this blog have probably seen the excellent and entertaining video “What motivates us” (http://www.youtube.com/watch?v=u6XAPnuFjJc), which really illustrates the distinction in the effectiveness of financial incentives for routine, mechanical tasks (very effective) vs more complex tasks requiring a lot of cognitive skills (not so effective). Much of health care is in the latter category, although many important interventions, such as immunizations, are more mechanical in nature. And after saying all of that, it is still worth noting that even though buying quality may be difficult, all countries face efficiency challenges, and financial incentives can be very effective in dealing with these. So again, there remains a strong case to blend “performance” (or output, productivity, efficiency, etc.) incentives into budget systems. And also worth a reminder, again, that this is not some unique “African” or low-income issue or approach. Blended payment mechanisms are really at the core of health financing reforms in many OECD and middle income countries. The concepts and ideas are universal.
Lastly, a few reflections on Bruno Meesen’s contribution. As with PBF, RBF, etc., we face a big terminological challenge around the words “health insurance”. As he notes, we are fundamentally concerned with risk pooling and financial protection, without preference to any particular institutional form. From my perspective, any mechanism other than pure out-of-pocket payment is a system of insurance, and as I’ve written in my prior role as WHO’s advisor for health financing in European countries, German citizens are not somehow more “insured” than British citizens just because of the label attached to their system, differences in the main source of funds, or differences in the basis for entitlement to benefits. Both systems insure their populations. And, in relation to this blog, both have gone a long way to incorporate elements of strategic purchasing. My interpretation of Bruno’s comments are that UHC should not be translated as one specific approach to health financing reform in African (or any) country. Another important message of the WHR2010 is that while the broad goals associated with UHC may be shared across countries, “solutions” (i.e. the reform pathway) must be home-grown. So to close (finally, sorry for being long-winded), I don’t have a particular position on the type of strategic purchasing mechanisms countries should adapt, I do believe that making purchasing more strategic – more targeted to health needs and provider performance – is an important pathway for strengthening health financing systems on the road to universal coverage.

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April Harding

3/4/2012 11:41:20 am

Joe rightly points out that our current research tends to focus on determining whether or not P4P “works”. He rightly urges us toward “more systematic effort to use the RBF/PBF initiatives to strengthen domestic health financing systems and capacities”.
The single largest constraint to doing this is that current RBF/PBF research consists of RCTs and other quantitative experimental and non-experimental quantitative evaluations – where RBF is “framed” and analyzed as a black-box homogeneous “treatment” to a group of provider organizations (without reference to the environment within which the organizations operate, or to the range of organizational characteristics which very predictably influence providers’ response to PBF). And the results we get are average scores of changes in performance variables. These evaluations leave us knowing little more than we did without them. And they certainly don’t tell us how to use PBF appropriately to “strengthen domestic finance systems” nor do they tell us how to “fit” a PBF policy to existing provider characteristics (even though there is substantial literature from developed countries confirming this “fit” is critical to success).
We urgently need to broaden the research agenda to include rigorous theory-based mixed method evaluations that are appropriate for assessing and understanding health systems reforms (which we know RBF reforms are). This is the only way we will start to shed light on which packages of PBF policies and capacity building activities “fit” which health system context.
The current bias in many journals may make it harder to get such research published; and, systematic reviews may exclude even the best studies of this sort. However, growing numbers of agencies and researchers are rejecting the use of exclusion/inclusion criteria developed for medical/ biological studies and structurally “contained” program activities, and are advocating for developing and using exclusion/inclusion criteria suited to health systems interventions). See this Rockers et al article in this month’s Health Policy http://www.healthpolicyjrnl.com/article/S0168-8510(11)00274-0/abstract
Even if this bias persists, as it doubtless will in certain circles, we have a responsibility to do the most relevant research to inform PBF reform design and implementation – given the magnitude of resources and effort currently devoted to these activities.

Several commentors have noted the mixed evidence so far for P4P. Most discussions I hear end up debating whether PBF "works" or does not work. These discussions are not helpful in the least.

What we need, and what our research must focus on is: when do the various strategies we lump together under the rubric P4P move provision in a positive direction (as measured by the coverage/ health/fin protection goals of interest). Which particular strategy best "fits" the health system in which the reform is being implemented?
This will require moving beyond RCTs, and other experimental, or quasi-experimental designs. We will need to use even qualitative methods (rigorously!) to measure things like: the degree to which the purchasing function is strengthened, for example.
Sadly, because of the fairly widespread misunderstanding of P4P strategies, it is assumed that these strategies can be sensibly evaluated in the same way as a programmatic and largely extra-systemic interventions (e.g. school-based deworming). As Joe (and Bruno) have made eminently clear, P4P is a health systems reform intervention - which requires theory-based evaluation, focused on shedding light on the links in the intervention chain (or mechanisms contained under the heading P4P) and critically, how each type of P4P strategy fits the existing financing system AND provider organization characteristics.
For example, Joe notes that P4P is widely used (and successfully) in OECD countries PHC systems. Why yes. That is true. But virtually all the countries where it is working are using it with private primary care organizations and practitioners.
P4P is also increasingly being applied in OECD hospital systems (implemented as an element of DRG or "activity based funding" systems). In public hospital systems, these P4P reforms are implemented together with (or following) hospital governance reforms which have made hospitals much more autonomous.
The point is: to measure the impact of a P4P reform without untangling the influence of the specific "reforms

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April Harding

3/4/2012 11:46:11 am

Sorry! ended up with an extra paragraph or two at the bottom of my comment (starting w "several commentators")

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Jurrien link

3/5/2012 03:22:13 pm

I am very pleased to find comments of this quality to my blog – hope you permit me to comment on these.
Firstly – the same confusion on terminology (PBF, RBF, P4P) happened in the site-meeting in Bangkok, and even Gyuri and I seem to have a different understanding. To my understanding the difference is the following: in P4P approaches, one institution determines the ‘results’, their ‘price’, and ‘verifies’ the results and then pays the provider. In the case of PBF and RBF, there is a clear split of function between purchaser, provider, regulator and verifier. The difference between these two is that PBF is about supply-side incentives only, while RBF refers to both supply- and demand-side incentives. I don’t pretend that this is the only right way to define the three – but let’s finally come to a common understanding to avoid further confusion…..

Secondly, I agree with all that UHC and P/RBF in potential could reinforce each other – if (as Sophie says) both are well crafted and implemented. Important here is what Kutzin writes, RBF represents a strategic purchaser mechanism of quality care (Health Insurance, by the way, does too) – and may enable purchasing ‘more health for the same buck’ – a key element to make UHC sustainable. How can I disagree with Bruno that MDG 4,5,6 are highly appropriate goals – but the issue is that it is often stated (and rightly so) that the risk in P/RBF is in causing ‘perverse effects’ on those interventions not addressing those MDGs. UHC can help to overcome this problem by purchasing the BBP instead of selective outputs. Also, priorities in P/RBF will then be ‘home-grown’ and not set by donors through a trust fund or other.

Thirdly, probably the most important issue in commenting the blog: all seem to agree that more evidence is needed regarding P/RBF. Indeed it was Sophie’s presentation that made me write the blog – I would prefer not to blame it on the Cochrane method, but to take up the glove. Sophie did not argue that P/RBF doesn’t work, but that ‘evidence is thin’; Gyuri agreed in a comment in the PBF-CoP Google group ([email protected]).
From my Bangkok notes I remember Kutzin said that “input-planning had already proven NOT to be effective”. If I quote him wrong (again), I don’t mind taking the responsibility for that quote myself – still I think that, if we want P/RBF to sustain, we need strong evidence to strengthen the approach itself. From what I have seen in the field, during my evaluations, as an implementer I also belief it works: health workers said they were more motivated because being permitted to be creative, clients said that they thought services had improved. But as a researcher I have my doubts: most ‘evidence’ derives from evaluations, based on service data, mostly provided by implementers who want to prove that P/RBF works. Many of the impact studies that I know (besides the one on Rwanda published in the Lancet) lack a serious, sound methodology – also because of a limited budget. This often quoted large evidence base shows the “probability” that P/RBF works – we need more than that: real evidence from studies based on thorough methodology.
The impact evaluations planned by the WB I know, are too narrow in their focus. I do agree with Bruno that we should not limit ourselves to impact evaluations “to prove that P/RBF works” – but also study “why” it works, “what” in RBF works and what does not, “in which context” (outside Rwanda and Burundi), what are “the determinants” to make it work. For example, I doubt with Kutzin if “P/RBF” works because of the “F”: in our pre-pilots in Mali and in Ghana I saw results improve in an important way by setting-up P/RBF arrangements: before we paid any financial incentive…. Unfortunately we did not set-up yet a thorough study next to it, so “no evidence”……..
I think experience with P/RBF is widespread enough to establish a joint agenda for research, between implementers and researchers – I would expect that funding agencies are interested in evidence, and will be prepared to finance studies deriving from this effort. I think P/RBF has too much potential to leave evidence at a “probability” level.

I hope that readers of this blog will join in setting-up such an agenda for research.

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Charles Wafula

3/9/2012 11:01:10 pm

This debate is one of the most interesting and relevant at the moment. Especially for resource constraint countries, health systems researchers particularly on UHC, this debate should lead us to the most relevant research topics and what level of methodologies to apply. The challenge, though, is the funding for research - but collaborative research then should be emphasized.

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Charles Wafula

7/27/2013 07:46:45 am

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Website link

8/20/2013 04:05:34 am

Nice information shred by this blog !!From my Bangkok observations I regard Kutzin said that “input-programma had once proven NEGATIVE to be efficient”. If I adduce him incorrect (further), I don’t mental taking the liability for that adduce myself – tranquil I think that, if we wish P/RBF to help, we demand sturdy document to steel the avenue itself. From what I get seen in the garden, while my opinions, as an implementer I further credit it processs: constitution toilers said they were another motivated since mortal permitted to be original, customers said that they mind employs had improved. Nevertheless as a researcher I hold my discredits: most ‘sign’ draws from opinions, based on employ information, mostly provided by implementers who desire to validate that P/RBF processs. Numerous of the impression studies that I comprehend (adjacents the unit on Rwanda published in the Lancet) scarcity a serious, sturdy methodology – plus therefore of a finite finances. This frequent quoted heavy testimony wicked fanfares the “probability” that P/RBF processs – we demand additional than that: authentic indication from studies based on full methodology.

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