Performance Incentives Expand Access to Lifesaving Health Services

Management Sciences for Health (MSH) leaders in performance-based financing (PBF) of health services shared their successful experiences from Haiti and Rwanda in a new book from the Center for Global Development, Performance Incentives for Global Health: Potential and Pitfalls.

The Haiti team, writing about scaling up a performance incentive model through a network of nongovernmental organizations (NGOs), found that rewarding NGOs for increasing access to a package of basic services and paying them for achieving performance targets resulted in significant increases in essential services such as immunizations and assisted deliveries. Paying NGOs for results also strengthened the institutions’ capacity to deliver services.

Remarkable improvements in key health indicators have been achieved over the six years that payment for performance has been phased in…. Performance on all indicators was stronger for the project as a whole than performance on similar indicators for the entire country. On average, performance-based NGOs in each contract period performed better than expenditure-based NGOs.
Chapter 9, “Haiti: Going to Scale with a Performance Incentive Model,”
by Rena Eichler, Paul Auxila, Uder Antoine, and Bernateau Desmangles

The group from Rwanda, which implemented performance incentives countrywide, found that “a national performance-based financing approach with both the public and private nonprofit health facilities is feasible in low-income countries.” Preliminary results show that PBF has the potential to reduce costs while improving the quality and coverage of services. For example, institutional deliveries increased in two provinces because of innovations such as the introduction of bonus payments for women who spend three days after delivery at a health center.

Between 2001 and 2004, the PBF group saw an increase of institutional deliveries of close to 11 percentage points, while the non-PBF group increased by only 3.0 percentage points…. The boost in institutional deliveries was primarily due to innovative strategies to attract women to deliver at health centers, such as the establishment of additional centers to bring services closer to beneficiaries, paying traditional birth attendants to bring women to health centers, and providing clothing for newborns...
Chapter 10, “Rwanda: Performance-Based Financing in the Public Sector,”
by Louis Rusa, Miriam Schneidman, Gyuri Fritsche, and Laurent Musango

MSH is continuing this groundbreaking work, which was carried out by Dutch NGOs, through the Rwanda HIV/PBF Project, a program funded by the US Agency for International Development. We are taking advantage of and refining the structures put in place and applying the lessons of earlier efforts. Those include the need to make sure that all the components of services, from staff to supplies, are in place simultaneously to deliver care.

Because it fosters and supports a culture of results, the performance-based approach has improved the motivation and supervision of health workers. In the words of a representative of one Haitian NGO, “the performance-based approach helped to generate team spirit….” This is consistent with findings from other settings, where enhanced supervision itself proved a powerful factor for change in public health systems.

And the result for clients? In Haiti and Rwanda, as health systems are strengthened through innovative approaches that include PBF, people are more satisfied with health services and more likely to use them.