Protocol for the evaluation of a quality-based pay for performance scheme in Liberia

Abstract

BackgroundImproving the quality of care at hospitals is a key next step in rebuilding Liberia’s health system. In order to improve the efficiency, effectiveness, and quality of care at the secondary hospital level, the country is developing a system to upgrade health worker skills and competencies, and shifting towards improved provider accountability for results, including a Graduate Medical Residency Program (GMRP) and provider accountability for improvements in quality through performance-based financing (PBF) at the hospital level.Methods/designThis document outlines the protocol for the impact evaluation of the hospital improvement program. The evaluation will provide an estimate of the impact of the project and investigate the mechanism for success in a way that can provide general lessons about the quality of health care in low-income countries. The evaluation aims 1) to provide the best possible estimate of program impact and 2) to quantitatively describe the changes that took place within facilities as a result of the program. In particular, the impact evaluation focuses on the changes in human resources within the hospitals. As such, we use a three-period intensive evaluation of treated and matched comparison hospitals to see how services change in treated hospitals as well as a continuous data collection effort to track the activities of individual health workers within treated hospitals.DiscussionWe are particularly interested in understanding how facilities met quality targets. Did they bring in new health workers with higher qualifications? Did they improve the knowledge or competence of their existing staff? Did they improve the availability of medicines and equipment so that the capacities of existing health workers were improved? Did they address the motivation of health workers so that individuals with the same competence and capacity were able to provide higher quality? And, if they did improve quality, did patients notice?

The Three-Gap Model of Health Worker Performance

“…Thus, for each health worker who sees pediatric patients, we have multiple measures of their performance tied to their capacity and knowledge. The instruments and data collection are discussed in more detail in Bawo et al [21] and in the appendix.…”

The Three-Gap Model of Health Worker Performance

“…We illustrate the uses of this model using data from pediatric care units for a baseline evaluation of hospitals in Liberia (Bawo et al, 2015). In this evaluation, performance is measured with actual patients (do) as well as on vignettes designed to measure both knowledge and capacity.…”

“…For example, if a health worker knows that protocol requires the use of a particular medicine, but that medicine is out of stock, capacity will be lower than knowledge. The instruments and data collection are discussed in more detail in Bawo et al (2015) and in Appendix A. Figure 6 shows the average relationship among the three measures of quality for each health worker in the sample.…”

Health Labor Market Analyses in Low- and Middle-Income Countries: An Evidence-Based Approach

“…The World Bank has been instrumental in generating new data, evidence, and knowledge in the field of HRH to assist governments in analyzing and finding solutions to their health workforce challenges. Working under the coordinating leadership of ministries of health with national technical working groups on HRH, the Bank has been at the vanguard of using the theory and practice of labor economics to cast new light on the underlying factors that affect policy success or failure in health systems strengthening (see for example Leonard et. al 2015;McPake, Scott, and Edoka 2014;Vujicic and Zurn 2006).…”