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Abstract

Performance-based payment to providers: A new twist with institutional targets to improve facility performance 
Presentation at the American Public Health Association 139th Annual Meeting and Exposition, 2 November
Rahman,Laila; Rob,Ubaidur; Talukder,Md.Noorunnabi; Hena,Ismat Ara
Publication date: 2011

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Background
Effective human resource intervention is warranted to achieve the MDG target 5 in Bangladesh. Absenteeism is rampant in public health facilities, with almost 40 percent of doctors remaining absent. The demand-side-financing (DSF) model narrowly focuses on increasing pregnancy-related services by offering payment to the providers on a case-to-case basis without addressing institutional building and quality of care. In this context, the government has initiated a new model with incentives for improving institutional obstetric care performance.

Methods
Based on literature reviews and consultation with stakeholders, an institutional pay-for-performance (P4P) model has been developed, which allows incentives for individual providers for obtaining the institution's quantitative and qualitative targets. It employs Nash equilibrium, where all of the players' expectations are fulfilled and their chosen strategies are optimal toward achieving the institutional targets. Two levels of incentives tied with the basic salary are the incentives for achieving the targets.

Results
Three facilities achieved second-level, and eight facilities achieved first-level targets while one facility failed to meet any target. The number of cesarean sections in three emergency obstetric facilities increased by 20 percent to 194 percent, and normal deliveries at 11 facilities increased by 20 percent to 265 percent. The model motivated facility management and facility-based quality assurance teams of about 600 members to make the emergency room, labor room, obstetric ward, children's ward, and operation theater functional. Triggered with new ideas, motivated managers and providers went beyond borders to make the services efficient and functional by introducing use of partographs, establishing antenatal and breastfeeding corners, ensuring privacy and confidentiality, and taking infection prevention measures.

Conclusions
Instead of piecemeal-basis improvement of providers' quantitative services of the DSF model, the P4P model is superior for in-built facility strengthening and employing standardization in quantitative and qualitative achievements. This model can also be applied in other developing-country settings.

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