PRB

(July 2011) The benefits of integrating family planning (FP) into maternal and child health (MCH) services go beyond improving access to FP. Integration can increase the number of trained health care personnel who are responsive to the needs of children and mothers, improve management of the health care system, and address the reproductive health of women while requiring fewer patient visits. In addition, clients may be more satisfied because health care providers are able to address multiple needs, leading to overall increased use of services and improved health outcomes.¹

But how can women be encouraged to use these integrated services? How can the added workload be addressed? Performance-based incentives are one viable option.

What Are Performance-Based Incentives?

Performance-based incentives reward health providers, facilities, organizations, or patients for providing or using specific health services.² Alternatively called “results-based financing” or “performance-based financing,” incentives can be money or material goods. Although usually viewed as rewards to providers and facilities (referred to as “supply-side” incentives), incentives can also be provided to the client. An example of a “demand-side” incentive is a conditional cash transfer in which mothers receive payment if they fulfill the requirements established by the incentive program. Additional demand-side incentives related to FP and MCH integrated services might include payments made to mothers when they bring their children regularly to a designated health facility, or a subsidized set of vouchers to receive maternal care and FP at reduced cost.

How Do Performance-Based Incentives Improve FP/MCH Integration?

In many countries, FP and MCH services in the public sector are provided separately, imposing extra burdens of time and expense on women.³ If these services are integrated, the same provider may be trained to offer additional services such as FP counseling and contraception as part of a designated full package of maternal and newborn health care. Performance-based incentives can help motivate health workers to conscientiously carry out their added duties. Incentives for achieving certain FP and MCH outcomes or for implementing a quality improvement plan can be paid directly to providers or to health facilities. At the same time, subsidies for clients may raise their awareness of integrated FP/MCH services, reduce their travel costs, and increase their motivation to visit health centers or community health workers for FP/MCH services.

Incentives for Health Providers

To participate in performance-based incentive schemes, health workers must first be trained to provide an integrated package of services and facilities must establish a certain standard of quality care for clients. An accurate monitoring and evaluation system is needed to track performance-based indicators.

By rewarding service providers based on the quality and type of health services they provide, Performance-based incentives have the potential to increase accountability, enhance service-delivery capacity, strengthen health information systems, and improve the effectiveness of the health care workforce.⁴

The Rwanda Experience

Performance-based incentives were used in Rwanda to improve provider performance and increase the use of health services. In pilot projects conducted between 2002 and 2005 in Butare and Cyangugu provinces, incentives were paid to contracting facilities and staff based on the quantity and quality of health services delivered. Health insurance plans for the poor were also established to improve access to services.

In 2005, the World Bank compared the results achieved in Butare and Cyangugu with two other provinces, Gikongoro and Kibungo, which received assistance to improve their health systems but did not use a performance-based incentive approach.⁵ By 2004, an endline survey showed that child births in institutions had increased by 89 percent in provinces with incentive schemes compared with 45 percent in provinces without incentives. And coverage in Butare more than tripled as compared with Gikongoro, due to the success of strategies to attract women to deliver at health centers—additional centers to bring services closer to beneficiaries, payments to traditional birth attendants to bring women to health centers, and provision of newborn clothing to women who delivered at a facility.

Percent of Women Having Institutional Deliveries in PBI and Non-PBI Provinces

Before and After the Rwanda Pilot Project

Source: Robert Soeters, Laurent Musango, and Bruno Meessen, Comparison of Two Output-Based Schemes in Butare and Cyangugu Provinces With Two Control Provinces in Rwanda (Butare, Rwanda, Antwerp, Belgium, and The Hague, Netherlands: Institutional Deliveries, 2005): table 37.

Key stakeholders, such as donors, implementing organizations, and the Rwandan Ministry of Health believe that the scheme has contributed greatly by establishing a results-oriented culture, strengthening supervision, and promoting innovative strategies for improving coverage.⁶

Based on the pilot project experience, a standardized set of core services, a unique fee structure, and performance-based incentive contracts were developed and scaled up to cover 23 districts in 2005. The successful scheme became national policy in the 2005-2009 Health Strategic Plan and was incorporated into Rwanda’s National Finance Law.

Subsidizing Travel and Services in Pakistan

The Greenstar Social Marketing network in Pakistan is one of the world’s largest. In 2008-2009, it piloted a voucher scheme in Dera Ghazi Khan District in Punjab to encourage poor pregnant women to seek maternal health and FP services. Women purchased vouchers at a subsidized price and received care from selected Greenstar network providers who were reimbursed to provide the covered services and to pay voucher holders for their transport costs. The voucher scheme was a success: More than 98 percent of women with vouchers delivered at health facilities whereas 97 percent had previously delivered at home.⁷ More than three-quarters of women returned for FP counseling after delivery. Donor funding for the pilot project ended in 2009 but in the same year, Greenstar began to implement two similar voucher projects in Jhang and Charsadda districts in Central Punjab with a greater focus on sustainability.⁸

Challenges

Performance-based incentives offer promising support to FP/MCH integration but success depends on an intensive, collaborative, and flexible effort to design the program and then monitor results and fix any problems that occur during implementation.⁹

• Consider country context. Developers of performance-based incentives must consider the social and political realities within their countries, including the timeliness and quality of information systems, the ability to transfer money securely through banks, and restrictions imposed by donors, governments, and NGO management.
• Set goals that can be measured and achieved. Performance-based incentive systems need specific, measurable, and realistic goals to be successful. Vague or overly ambitious or complex goals are not useful. Similarly, indicators should be specific and measurable, and targets attainable within a specified contract period.¹⁰
• Choose the incentive type and amount carefully to ensure voluntarism. Because performance-based incentives can be a powerful tool for increasing FP/MCH services, it is critical to consider the purpose of the incentive and monitor unintended consequences such as coercion. Including FP within a performance-based incentive requires a commitment to the client’s right to voluntary and informed choice.¹¹
• Monitor and validate performance. Verifying whether targets are met, tracking what is working or what needs to be changed, and evaluating the effects of the program on health outcomes is essential.
• Strike clear agreements so all players know what is expected. Contracts and performance agreements should specify targets, how they will be measured, and how payment will be linked to their attainment. Contracts should specify the payment formula, mechanisms for resolving disputes, reasons for termination of the contract, and responsibilities of the recipient and purchaser.¹²

Mia Foreman is a policy analyst at the Population Reference Bureau.

References

1. Stephan Kinoti, Effects of Performance-Based Financing on Maternal Care in Developing Countries: Access, Utilization, Coverage and Health Impact. Rapid Review of the Evidence (Washington, DC: USAID TRAction Project, 2011).
2. The Center for Global Development Performance Based Incentives Working Group.
3. Y. Jaffré and J.P. Olivier de Sardan, Une Médecine Inhospitalière: Les Difficiles Relations Entre Soignants et Soignés Dans Cinq Capitales d’Afrique de l’Ouest (Paris: Karthala, 2003).
4. Rena Eichler and Ruth Levine, Performance Incentives for Global Health: Potential and Pitfalls (Washington, DC: Center for Global Development, 2009).
5. R. Soeters et al., “Comparison of Two Output-Based Schemes in Butare and Cyangugu provinces With Two Control Provinces in Rwanda, 2005,” meeting report (September 2005), Kigali; World Bank, Global Partnership on Output-Based Aid.
6. Louis Rusa et al., Rwanda: Performance Based Financing in the Public Sector (Washington DC: Center for Global Development, 2009).
7. Hamid Bashir et al., Pay for Performance: Maternal Health Services in Pakistan (Bethesda, MD: Health Systems 20/20 Project, 2009), accessed at www.healthsystems2020.org/content/resource/detail/2577/, on June 10, 2011.
8. A. Saleh and S. Agha, New Approaches to Demand-Side Financing: The Jhang Voucher Scheme (Karachi: Greenstar Social Marketing, 2011).
9. Eicher and Levine, Performance Incentives for Global Health.
10. Eicher and Levine, Performance Incentives for Global Health.
11. Rena Eichler et al., United States Agency for International Development: Performance-Based Incentives Primer for USAID Missions (Washington DC: USAID, 2010).
12. Eicher et al., United States Agency for International Development.