The Effect of Performance-Based Financial Incentives on Improving Health Care Provision in Burundi: A Controlled Cohort Study

Abstract

To strengthen the health care delivery, the Burundian Government in collaboration with international NGOs piloted performance-based financing (PBF) in 2006. The health facilities were assigned - by using a simple matching method - to begin PBF scheme or to continue with the traditional input-based funding. Our objective was to analyse the effect of that PBF scheme on the quality of health services between 2006 and 2008. We conducted the analysis in 16 health facilities with PBF scheme and 13 health facilities without PBF scheme. We analysed the PBF effect by using 58 composite quality indicators of eight health services: Care management, outpatient care, maternity care, prenatal care, family planning, laboratory services, medicines management and materials management. The differences in quality improvement in the two groups of health facilities were performed applying descriptive statistics, a paired non-parametric Wilcoxon Signed Ranks test and a simple difference-in-difference approach at a significance level of 5%. We found an improvement of the quality of care in the PBF group and a significant deterioration in the non-PBF group in the same four health services: care management, outpatient care, maternity care, and prenatal care.The findings suggest a PBF effect of between 38 and 66 percentage points (p<0.001) in the quality scores of care management, outpatient care, prenatal care, and maternal care. We found no PBF effect on clinical support services: laboratory services, medicines management, and material management.The PBF scheme in Burundi contributed to the improvement of the health services that were strongly under the control of medical personnel (physicians and nurses) in a short time of two years. The clinical support services that did not significantly improved were strongly under the control of laboratory technicians, pharmacists and non-medical personnel.

Payment methods for outpatient care facilities

“…Four studies evaluated P4P for general practitioner practises in the United Kingdom (Alshamsan 2012; Lee 2011; McLintock 2014; Serumaga 2011). Nine studies were conducted in the United States, of which two included community mental health centres (Catalano 2000; Catalano 2005).…”

“…For the outcome measures, payment was based on patients' health or behaviour outcomes, for example the percentage of patients with blood pressure controlled (Alshamsan 2012; Bardach 2013; Petersen 2013), total cholesterol control (Alshamsan 2012; Lee 2011), or the percentage of smokers with seven-days sustained abstinence from smoking (Roski 2003). There were also several P4P programs that used combined process and outcome performance measures (Alshamsan 2012; Bardach 2013; Lee 2011; Petersen 2013; Serumaga 2011). …”

“…There are two main categories in the included P4P methods: threshold payment and payment for each instance of performance. Threshold payment means that the providers only received the performance incentives if they achieved a certain level of performance, and this level of performance could be absolute performance or relative performance compared with other providers or their previous performance, for example at least 40% of covered patients with diabetes who have a record of total cholesterol (Alshamsan 2012; Lee 2011; Serumaga 2011), the outpatient utilisation rate achieving at least 0.6 per resident and the facility-based delivery achieving at least 20/1000 (Canavan 2008), referral of at least 50 smokers (An 2008), percentage of tobacco status identified achieving 15% above the average performance (Roski 2003), or being one of six facilities with the highest compliance scores or one of three facilities improving the most from a previous audit (Hillman 1998; Hillman 1999). Payment for each instance of performance means providers received an award for each instance of service provision or patient's health improvement, for example payment of USD 20 for one case of blood pressure control (Bardach 2013), USD 15 for one glycated haemoglobin test (Chien 2012), or USD 18.20 payment for one blood pressure control or appropriate response to uncontrolled blood pressure (Petersen 2013).…”

“…Some P4P incentives accounted for less than 10% of total income level of health facilities or individuals (Bardach 2013; Canavan 2008; Petersen 2013); in two P4P programs evaluated in four studies (Alshamsan 2012; Basinga 2011; Lee 2011; Serumaga 2011), incentive levels were about 20% to 25% of total facilities' income; in one program in Burundi (Soeters 2008), the P4P payments constituted 58% of facilities' revenue. In three studies, the levels of incentive were only compared with part of the facilities' revenue (20% of capitation for some female members 50 years of age and older) (Hillman 1998; Hillman 1999); 30% of capitation fee from one insurance plan (Yip 2014)).…”

Performance-based financing contributes to the resilience of health services affected by the Liberian Ebola outbreak

“…While a recent systematic review focusing on low-and middle-income countries came to the conclusion that stronger empirical evidence is needed on whether or not PBF is cost-effective, 21 there are reports of PBF schemes benefiting health service delivery in hard-to-reach areas in Rwanda and Burundi and the conflict setting of the Democratic Republic of Congo. 3,[22][23][24] This being said, we do not really know why Bong County performed better than Margibi County and whether this had anything to do with PBF. Margibi appeared to have a more severe Ebola outbreak than Bong and, although the two counties were matched in some respects, they also differed in others, as discussed above.…”