Protocol for the evaluation of a pay for performance programme in Pwani region in Tanzania: A controlled before and after study

Abstract

BackgroundThe use of supply-side incentives to increase health service utilisation and enhance service quality is gaining momentum in many low- and middle-income countries. However, there is a paucity of evidence on the impact of such schemes, their cost-effectiveness, and the process of implementation and potential unintended consequences in these settings. A pay for performance (P4P) programme was introduced in Pwani region of Tanzania in 2011.Methods/designAn evaluation of the programme will be carried out to inform a potential national rollout. A controlled before and after study will examine the effect of the P4P programme on quality, coverage, and cost of targeted maternal and newborn healthcare services and selected non-targeted services at facilities in Tanzania. Data will be collected from a survey of 75 facilities, 750 patients exiting consultations, over 75 health workers, and 1,500 households of women who delivered in the previous year, in all seven intervention districts. Data will be collected from the same number of respondents in four control districts. A process evaluation will examine: whether the P4P programme was implemented as planned; stakeholder response to the programme and its acceptability; and implementation bottlenecks and facilitating factors. Three rounds of process data collection will be conducted including a review of available P4P documents, individual interviews and focus group discussions with key informants working at facility and district level in five of the intervention districts, and at the regional and national levels. An economic evaluation will measure the cost-effectiveness of P4P relative to current practice from a societal perspective.DiscussionThis evaluation will contribute robust evidence on the impact and cost-effectiveness of P4P in a low income setting, as well as generate a better understanding of the feasibility of integrating complex intervention packages like P4P within health systems in resource poor settings.

In Tanzania, The Many Costs Of Pay-For-Performance Leave Open To Debate Whether The Strategy Is Cost-Effective

“…30 The household cost of pay-for-performance was defined as the average baseline household cost for delivery at a facility multiplied by the additional number of facilitybased deliveries attributable to pay-for-performance, plus the average baseline household cost for delivery at home multiplied by the reduction in the number of home-based deliveries attributable to pay-for-performance. Transportation costs related to seeking care for delivery were not included.…”

“…30 We used difference-indifferences regression analysis to estimate the impact of pay-for-performance on the nine target indicators. We verified that trends in a number of outcomes were similar in the intervention and comparison areas before the introduction of pay-for-performance.…”

Organizational theory for dissemination and implementation research

“…For example, studies have found institutional theory useful for explaining how an organization’s external environment influences the integration of evidence into practice [23] and which intervention components are most likely to be sustained [24]. TCE has been used to explain how organizational networks form [25] and why organizations engaged in pay-for-performance may “game” the system, inflating performance scores to maximize payment [26]. Shortell used institutional theory and TCE theory to understand the development and evaluation of accountable care organizations [27].…”

Improving quality of care through payment for performance: examining effects on the availability and stock‐out of essential medical commodities in Tanzania

“…Pwani region is one of 30 regions in the country and has seven districts with more than 209 health facilities and a population of just over a million . Financial incentives are given to health facilities, district and regional managers based on their performance on pre‐defined service delivery targets (Table ) . Most of the targets at facility level pertain to increases in service coverage, with four that involve the provision of medicines such as antiretroviral therapy (ART), IPT during ANC, vaccines and supplies such as partographs.…”