Five years ago, government decided to supplement primary health care services with a “cash for performance” program aimed at raising health worker morale and productivity. The Pay for Performance or P4P programs, at was dubbed, would make the staff deliver better quality services for the mothers and children.
Using 14 maternal and child healthcare output indicators, the government committed to reward clinics and facilities which provided services to the satisfaction of patients with a series of bonus cash payments.
Following an assessment of the P4P programs by a World Bank team, the Bank has reacted with excitement with proposals it should be adopted globally because of the “limited improvement in better health outcomes for people in developing countries.” The results are said to be causing great excitement in health and development circles.
The results of the assessment will be presented in Burundi at a major conference this week. The Rwanda P4P program shows significant, verifiable improvements in attended birth deliveries and preventive child health visits.”
“What’s so gratifying about this study is that it helps governments answer the eternal question of how to use their money to best advantage when they only have five dollars to spend on better health for every woman and child in the country,” says Christel Vermeersch of the World Bank’s Human Development Network and one of the lead evaluators of the new Rwanda study.
How the P4P programs work
If, for example, the facility meets all of the government’s quality criteria, then it receives an index score of one and receives full payment for the services. However, if the facility is deficient in some of the quality criteria, then all of the payments are discounted.
For example, if the facility only scores 0.80 on the quality index, then it only receives 80 percent of the payment for the P4P services. Patient follow-up surveys and polling are the key determinants of whether the services were considered satisfactory or not.
The evaluation studied 166 of Rwanda’s 401 primary care facilities over a 24 month period and backed up these findings with random samples of 13 households living in the local areas served by the clinics.
By offering the clinics the equivalent of US $1.83 for women who were new contraceptive users, $4.59 for each mother who delivered her baby safely on their premises with skilled midwives, $1.83 for each referral of a malnourished child for treatment (almost 50 percent of children in Rwanda are stunted), and 92 cents for every child who completed vaccinations on time, the P4P program achieved significantly increased use and quality of a number of critical maternal and child health services.
The World Bank said in a statement that this program is coming at the right time. Although donor funding for health has increased dramatically over recent years, the Bank says there has been limited improvement in better health outcomes for people in developing countries.
This situation, the Bank adds, is a sobering reality considering that 2010 marks the five year countdown to the health Millennium Development Goals.
Aid budgets in wealthy OECD donor countries have also become a reluctant casualty of crisis. With less development aid in circulation, a relentless search is on to find winning development results that those fewer aid dollars can maximize returns on.
Dr. Paulin Basinga, one of the lead evaluators from the National University of Rwanda’s School of Public Health, will discuss the World Bank study at the Burundi conference.