By Rebekah Mintzer
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| A recent study examined the implementation of pay-for-performance medicine in Rwandan health care centers like this one. (Photo credit: Flickr User dmason/ Creative Commons.) |
P4P is a system in health policy, fairly new to the developing world, that rewards providers financially for providing care with quality and frequency based on “indicators” like visits to the facility, checkups, vaccinations or treatments, and formal quality control evaluations.
“The study definitely shows that the P4P model was effective in Rwanda. What’s interesting and helpful in the development context is that it’s about using money in a smarter way, rather than just using more money,” Dr. Christel Vermeersch an economist with the Human Development Network with the World Bank and a co-author of the impact report told MediaGlobal.
Starting in 2005, the Rwandan government began using a P4P system at primary care centers nationally. This system augments existing facility budgets with bonuses based on a formula that combines quantity and quality of medical treatment. The Rwanda study examined 166 primary care centers over 24 months based on 14 output indicators related to prenatal care, delivery, and child preventative care. These indicators included expecting mothers delivering in hospitals, women being given contraceptives, and expectant mothers receiving tetanus shots. If such indicator tasks were completed, the primary care centers received bonus money based on a formula that also took into account the overall quality of the facility and its services. The quality index score for medical facilities was determined based on quality control visits by government officials and follow-up surveys of area families who used these medical services.
For example, one indicator used in Rwanda P4P was the timely vaccination of children. For each child that a primary care center vaccinated completely and on time, they received a 92-cent cash bonus. However, if the medical center only scored a .75 on the quality index, they would only be given 75 percent of total P4P bonus funds for vaccinating that child.
The study concluded that P4P is linked with higher quality medical care, particularly when the specific indicator depends more on the efforts of the provider rather than on the decisions of the patient. It also demonstrated that the higher the bonus payment for providing a particular service through P4P, the more initiative health care providers took in performing it.
Though successful on the ground in this impact study, there are some potential challenges associated with P4P. “[P4P] could create a wrong culture of pay for everything and may damage the solidarity mechanisms,” Dr. Varatharajan Durairaj of the Department of Health Systems Financing at the World Health Organization (WHO) told MediaGlobal . “Besides, P4P is an expensive measure and therefore, may not be sustainable.”
“For P4P to work, the Rwandan government had to make a large up-front investment in technical assistance, said Vermeersch. “This makes sense: if you want to pay based on performance, you better be able to measure that performance! And once you start paying for performance, you need to continue monitoring the numbers.”
According to both Vermeersch and Durairaj, more information and real world data are needed before definitive conclusions and well-informed policy decisions can be reached about P4P medicine in developing nations. The World Bank is planning on conducting another study of P4P in Rwanda as well as a series of comparable studies through the Multidonor Health Results Innovations Trust Fund in six other developing nations to further investigate the effectiveness of the P4P model.
