Global Landscape Analysis. Case studies have been developed on PBI programs in Mozambique, Nigeria, the Democratic Republic of the Congo, Senegal and Malawi.
In order to develop a global landscape analysis, ThinkWell conducted a literature review on quality within PBI programs and produced an annotated bibliography. The annotated bibliography summarized peer-reviewed and grey literature on PBI interventions with a QoC component, cataloguing which types of services were incentivized and described the QoC measurement tools utilized in each scheme. ThinkWell also produced a database of current PBI projects with specific QoC improvement objectives and furthermore, a database of current PBI projects with specific QoC quantity indicators. The matrices lists PBI projects by country and funder, describes each program, lists the types of services incentivized, and describes the QoC tool utilized by the scheme to measure either quality or quantity.
ThinkWell compiled a database of QoC indicators found in program quality checklists, which are used to measure quality within PBI schemes and another database of QoC indicators found in program quality checklists, which are used to measure quantity within PBI schemes. The databases classify each indicator by health service level (primary, secondary), dimension (hygiene and sanitation, privacy, family planning counseling, etc.), indicator description, score, and indicator type (structural, process, output).
The analysis identified 32 PBI implementations with QoC improvement objectives between 2008-2015 in 28 low and middle income countries (predominantly in Sub-Saharan Africa). These projects were funded by national governments, the World Bank, USAID, CDC and the German Development Bank KfW. The majority of programs were funded by the World Bank. To date, ThinkWell cataloged approximately 8,490 quality indicators in a database. On average, checklists contained 125 indicators; within the same program. Using the Donabedian framework, 80% of indicators were structure-type, 19% process-type, and 1% outcome-type. Furthermore, 57% of indicators related to availability of resources, 25% to managing the facility and 17% assess the competence and effort of clinicians. This dataset is the largest in existence providing robust information on how QoC is being incentivized within PBI.
The indicators were classified into 6 dimensions of QoC:
From these analyses, ThinkWell identified country PBI programs on which to develop in-depth case studies that examined the how and to what extent countries were incentivizing quality of care. Case studies were developed on PBI programs in Mozambique, Nigeria, the Democratic Republic of the Congo, Senegal and Malawi. These case studies combined information from document reviews, in-depth interviews with key informants, and a review of available national facility-level on quality indicators.
Donors and country implementers are increasingly interested in incorporating quality improvement objectives into PBI programs globally. These key stakeholders want to learn the best ways to incorporate quality into programs, including which indicators are most appropriate and feasible to measure, how to verify quality scores, and the effect of quality checklists on provider behavior and health outcomes. The case studies were presented to donors and country implementers at workshops and conferences throughout 2016, including a workshop co-hosted by TRAction and Harvard’s Maternal Task Force and another workshop co-hosted by the World Bank and USAID|TRAction. This study provided a rich analysis of how PBI programs incentivize different types of services, how checklists and indicators have changed over time, and how programs contain costs associated with score verification. Findings from this study offer a high-level, global comparison of paying for QoC within PBI programs. The outcomes of this research informed PBI program planners as they target low-performing service areas in the future.
Jessica Gergen, ThinkWell Global