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Global Landscape Analysis of Quality within PBI Programs

Women waiting at a health clinic. Photo Credit: URC.

The Challenge

Globally, research has demonstrated that Performance-Based Incentives (PBI) programs are effective in increasing the quantity of health services provided. In comparison, there is little evidence for the effect of PBI programs on quality of care (QoC) provided to patients. For programs that do have a quality component, providers are often scored based on structural indicators of quality over which they have little to no control, such as infrastructure, equipment and availability of pharmaceuticals. Program implementers recognize the need to move from these structural indicators of quality to process and outcome indicators, including the competence, knowledge application, and effort of clinicians; meetings organized; and hygiene and facility plans in place. TRAction aims to build an evidence base on the effect of PBI programs on these dimensions of quality of care. 

Addressing the Challenge

TRAction selected Thinkwell to carry out a landscape analysis and develop several country case studies that demonstrate how and to what extent QoC has been incorporated into PBI programs globally. The analysis includes a compilation of information on quality indicators, data verification, and the revision process used to improve PBI programs. In addition, the analysis will examine different methods, frequency, and costs associated with score verification. From this analysis, Thinkwell and TRAction have identified five country PBI programs on which in-depth case studies are being developed. The case studies examine how program planners and implementers have incentivized quality of care within the unique context of each country’s PBI program. 

Project Location

Global Landscape Analysis. Case studies have been develop on PBI programs in Mozambique, Nigeria, the Democratic Republic of the Congo and Senegal. A fifth case study on Malawi is forthcoming.

Research Objectives

  • To conduct a landscape analysis of all PBI programs implemented globally
  • To catalogue and map PBI program indicators, checklists, and verification procedures by technical area and system level
  • To develop country case studies on the planning and implementation of PBI programs that focus on quality of care

Study Approach

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 summarizes peer-reviewed and grey literature on PBI interventions with a QoC component, cataloguing which types of services are incentivized and describing the QoC measurement tools utilized in each scheme. Thinkwell also produced a database of current PBI projects with specific QoC improvement objectives. The matrix 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 quality.

Thinkwell has compiled a database of QoC indicators found in program quality checklists, which are used to measure quality within PBI schemes. The database classifies 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).

Preliminary Findings

  • The analysis identified 32 PBI projects with QoC improvement objectives currently being implemented in 29 low and middle income countries. These projects are funded by national governments, the World Bank, USAID, CDC and the German Development Bank KfW.
  • To date, Thinkwell has catalogued approximately 8,500 quality indicators in a database. This dataset is the largest in existence providing robust information on how QoC is being incentivized within PBI. 
  • The indicators have been classified into 6 dimensions of QoC: 
  1. Resource Availability – The structural resources required to delivery quality care (structural)
  2. Pharmaceutical Availability – The pharmaceutical and consumable resources required to delivery quality care (structural)
  3. Facility Management – The management processes required to ensure that the health facility functions optimally to deliver quality care (process)
  4. Competence of Clinician – The clinician has the clinical knowledge required to care for, or diagnose and treat, patients (process)
  5. Effort of Clinician – The clinician correctly applies appropriate clinical knowledge based on the latest medical teaching to deliver quality care (process)
  6. Other – A variety of types of indicator which don’t fit easily into these other dimensions
The study team plans to produce a summary analysis of this vast database, highlighting key metrics and trends in quality indicators. 

Country Case Studies

From this analysis, Thinkwell identified country PBI programs on which to develop in-depth case studies that examine the how and to what extent countries are incentivizing quality of care. Case studies have been developed on PBI programs in Mozambique, Nigeria, the Democratic Republic of the Congo, and Senegal, with a fifth one on Malawi forthcoming. These case studies combine information from document reviews, in-depth interviews with key informants, and a review of available national facility-level on quality indicators. 

Research Into Action

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 are 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. When completed, this study will provide 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 will inform PBI program planners as they target low-performing service areas in the future.

Research Partners

Thinkwell Global

Principal Investigator 

Jessica Gergen, Thinkwell Global

Project Status

Country / Countries: