Pay-for-Performance (P4P) to Increase Use of Maternal, Neonatal, and Child Health Services in Bangladesh

Financial incentives based on provider performance can improve maternal, neonatal, and child health care in Bangladesh.

The Issue

In Bangladesh, far too many pregnant women die during pregnancy or while giving birth. And far too many children die before the age of 5. The risk of both maternal and neonatal mortality is reduced when women use skilled prenatal, delivery, and postnatal care. However, suboptimal performance by service providers has been a key barrier to improving the availability and quality of maternal, newborn, and child health (MNCH) services.

The Progress

Through a series of research studies, the Population Council developed, tested, and implemented a refined team-based pay-for-performance (P4P) model that significantly improved the quantity and quality of maternal and newborn health services provided at selected public-sector facilities in underserved areas of Bangladesh. Under the P4P model, a facility is provided with quarterly targets for the number of women served and the quality of care provided to each service recipient. Initial targets are based on the facility’s prior one-year average; in subsequent quarters, once targets have been met they are increased based on mutual agreement with the facility staff.

For each quarter that targets are met, every member of the facility’s MNCH team receives an additional one-month’s basic salary as an incentive. If targets are exceeded, staff receive a bonus equivalent to 1.5 months of basic salary. These financial incentives are intended both to improve the services women receive and to motivate providers to remain in remote or rural areas.

The Council completed an initial study in 2009 on the feasibility of introducing a P4P financing mechanism, funded by the Center for Global Development, followed by an operations research study funded by UNICEF to develop and test the model. The Council completed the 30-month operations research study in August 2012 at 12 government health care facilities, serving more than 69,000 women. 

The Council, through printed and web-based reports and scientific publications, had made the results of the project widely known and available.

The Impact

The P4P model successfully improved the quality of maternal health services offered in health care facilities, and in turn encouraged more women to use these services. At the 12 health care facilities participating in the study, the volume of skilled antenatal services pregnant women received almost tripled, delivery services doubled, and postnatal services quadrupled.

The Population Council is credited for pioneering the performance-based provider incentive approach in the health sector in Bangladesh. The project also tested an automated quality assurance tool, which would provide a useful platform for the government to integrate the quality of care framework into its health service delivery systems.

Principal Investigator

  • Ubaidur Rob Senior Associate & Bangladesh Country Director, Bangladesh

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