Abstract
Low quality of care is a significant problem for health systems in low-income and middle-income countries (LMICs). Policymakers are increasingly interested in using performance-based financing (PBF), a system-wide provider payment reform, conditioned on both quantity and quality of performance, to improve quality of care. The health system context influences both the design and the implementation of these programmes and thus their effectiveness. This study analyses how context has influenced the design and implementation of PBF in improving the quality of primary care in one particular setting, Cote d’Ivoire, a lower-middle income country with some of the poorest health outcomes in the world. Based on literature, an analytical framework was developed identifying five pathways through which financial incentives can influence the quality of primary care: earmarking, conditioning, provider behaviour, community involvement and management. Guided by this framework, semistructured interviews were conducted with policymakers and providers to diagnose the context and to assess the links between financing and quality of care at the primary care level. PBF in Cote d’Ivoire was found to have increased data availability and quality, facility-wide and disease-specific inputs, provider motivation and management practices in contracted facilities, but had limited success in improving process and outcome measures of quality, as well as community involvement and the provision of non-incentivised services. These limitations were attributable to a centralised health system structure constraining the decision space of health providers; financing and governance challenges across the health sector; and shortcomings with regard to the design of the PBF quality checklist and incentive structures in Cote d’Ivoire. In order to improve the quality of primary care, health sector reforms such as PBF should incorporate the organisational and service delivery context more broadly into their design and implementation, as is the case in other countries.
Highlights
IntroductionLow quality of care is a significant problem in many low-income and middle-income Key questionsWhat is already known? ►► Performance-based financing (PBF) has been implemented in over 50 lower-income and middle-income countries, where it has succeeded in improving service utilisation and structural and process measures of quality of care.What are the new findings? ►► In contracted facilities in Cote d’Ivoire, performance-based financing (PBF) resulted in improvements in data availability and quality, levels of facility-w ide and disease-s pecific inputs, and provider motivation and management practices. ►► It was less successful in improving process and outcome measures of quality. ►► These limits were attributable to an overly centralised health system constraining the decision space of health providers; financing and governance issues across the health sector; and the design of the quality checklist and incentive structures.What do the findings imply? ►► Accounting for organisational and service delivery context in the design and implementation of health sector reforms, as well as a consideration of political economy factors, can improve such reforms’ effectiveness in improving quality of primary care.countries (LMICs): in 2016, 8.6 million excess deaths were attributable to low quality care, of which 5 million were due to poor-quality care and 3.6 million were due to non-u tilisation.[1]
This is a problem for primary care, which continues to be the first point of contact with the health system for many people, especially in low-income and middle-income countries (LMICs) such as Cote d’Ivoire, where over 70% of care is sought at the primary level.[2]
Due to the limitations imposed by the health system context, performance-based financing (PBF) led to a successful, but partial, pattern of improvement
Summary
Low quality of care is a significant problem in many low-income and middle-income Key questionsWhat is already known? ►► Performance-based financing (PBF) has been implemented in over 50 lower-income and middle-income countries, where it has succeeded in improving service utilisation and structural and process measures of quality of care.What are the new findings? ►► In contracted facilities in Cote d’Ivoire, PBF resulted in improvements in data availability and quality, levels of facility-w ide and disease-s pecific inputs, and provider motivation and management practices. ►► It was less successful in improving process and outcome measures of quality. ►► These limits were attributable to an overly centralised health system constraining the decision space of health providers; financing and governance issues across the health sector; and the design of the quality checklist and incentive structures.What do the findings imply? ►► Accounting for organisational and service delivery context in the design and implementation of health sector reforms, as well as a consideration of political economy factors, can improve such reforms’ effectiveness in improving quality of primary care.countries (LMICs): in 2016, 8.6 million excess deaths were attributable to low quality care, of which 5 million were due to poor-quality care and 3.6 million were due to non-u tilisation.[1]. ►► Performance-based financing (PBF) has been implemented in over 50 lower-income and middle-income countries, where it has succeeded in improving service utilisation and structural and process measures of quality of care. ►► Accounting for organisational and service delivery context in the design and implementation of health sector reforms, as well as a consideration of political economy factors, can improve such reforms’ effectiveness in improving quality of primary care. Common approaches focus on organisational design, management and organisational processes, and incentives.[3] In order to improve quality of care, policymakers have predominantly used clinic-level or provider-level interventions, with limited effectiveness.[4] Recent research emphasises the role of health system-level factors such as financing and governance on improving quality of care.[5]
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