Abstract
PBF program designers have traditionally selected and priced service delivery indicators based on public health value, and whether the indicator is SMART (specific, measurable, achievable, relevant, and timely). This approach ignores the providers perspective on the value of inputs and opportunity costs of service provision. We conducted in-depth interviews, focus group discussions, and rank order exercises with health workers to elucidate factors that drive their motivation to deliver PBF incentivized services. Health workers identified three key considerations that drive service prioritization: effort to acquire a patient, effort to treat a patient, and health worker locus of control. Health workers consider multiple factors when prioritizing PBF services to maximize their total reward. In pricing PBF services, program designers must understand inputs’ value and total opportunity costs, rather than relying on public health value and the SMART indicator framework alone. When pricing services, PBF program designers should collaborate with health workers to account for the range of factors that health workers consider when alone. When pricing services, PBF program designers should collaborate with health workers to account for the range of factors that health workers consider when making service provision decisions.
 
Highlights
Performance-based financing (PBF) or pay-forperformance has demonstrated mixed, but promisingSoc. e Cult., Goiânia, v. 22, n. 2, p. 168-186, ago./dez. 2019.Is SMART the new stupid? Health worker perspectives on producing PBF indicators Yogesh Rajkotia results in achieving important public health targets (Paul; Remans, 2018; Renmans et al, 2017;Witter et al, 2012)
PBF schemes entail the payment of financial incentives to health workers based on their performance, measured by the quantity, or number of patients, provided a service (Fritsche; Soeters; Meessen, 2014; Renmans et al, 2016).To date, the majority of PBF programs have used similar performance indicators, focusing primarily on maternal and child health services (Paul; Renmans, 2018; Renmans et al, 2017).This generic replication across programs can perhaps be attributed to single donor dominance or the shared health challenges across the specific contexts of low and middle-income countries (LMICs)
They include health worker locus of control — the degree to which a health worker controls relevant factors, such as supply chain or absenteeism.Taken together, these factors reveal that despite global guidance, PBF designers must go beyond the SMART framework (Fritsche; Soeters; Meessen, 2014), recognize that providers will act on their own preferences, and consider the drivers of provider motivation (Lohmann et al, 2017; Lohmann et al, 2018)
Summary
Performance-based financing (PBF) or pay-forperformance has demonstrated mixed, but promisingSoc. e Cult., Goiânia, v. 22, n. 2, p. 168-186, ago./dez. 2019.Is SMART the new stupid? Health worker perspectives on producing PBF indicators Yogesh Rajkotia results in achieving important public health targets (Paul; Remans, 2018; Renmans et al, 2017;Witter et al, 2012). PBF schemes entail the payment of financial incentives to health workers based on their performance, measured by the quantity, or number of patients, provided a service (Fritsche; Soeters; Meessen, 2014; Renmans et al, 2016).To date, the majority of PBF programs have used similar performance indicators, focusing primarily on maternal and child health services (Paul; Renmans, 2018; Renmans et al, 2017).This generic replication across programs can perhaps be attributed to single donor dominance or the shared health challenges across the specific contexts of low and middle-income countries (LMICs). Guidance is featured in two of the four PBF toolkits, where the recommendation is for indicators to follow SMART (Specific, Measurable, Achievable, Relevant and Timebound) methodology; there is no discussion on how to price an indicator appropriately (Fritsche; Soeters; Meessen, 2014; Sina Health, 2018; The AIDSTARTWO Project, 2011; Toonen; Lodenstein; Coolen, 2012). From our experience with PBF programs, pricing of indicators has been based on what program designers or policy makers value or view as being important,without bringing in health workers perspectives
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