Repositioning in Action E-Bulletin
January 2011
Subscribe | Past Issues | Tell Your Story | French Translation
Strengthening Voluntary Family Planning Services with Performance-Based Incentives:
Potential and Pitfalls
What Are Performance-Based Incentives (PBI)?
Performance-based incentives – also referred to as pay-for-performance (P4P), performance-based financing, and results-based financing – refers to any program that transfers money or goods to patients when they take health-related actions (such as having their children immunized), health care providers when they achieve performance targets (such as immunizing a certain percentage of children in a given area), or sub-national levels of government when they succeed in ensuring that their population receives key services (such as proportion of women in a catchments area delivering in a health facility).¹ By linking incentives to results, PBI aims to revitalize the health workforce; focus attention on (and provide demonstrable evidence of) measurable results; strengthen information systems; build local capacity to manage and deliver health services; and, of course, improve health outcomes.
Performance-based incentives are increasingly being tried in developing countries to tackle a number of health challenges, including newborn, child and maternal health, family planning, malaria, HIV/AIDS, tuberculosis, and immunization. There are also emerging programs that aim to catalyze improvements in nutrition, safe water and sanitation, and management of chronic conditions. PBI is not presented as a panacea, but the evidence strongly suggests it can strengthen health systems and improve health outcomes for the poor in developing countries.
Strengthening Voluntary Family Planning (FP) through PBI
Carefully designed PBI schemes can be a boon to efforts to strengthen access to and supply of quality voluntary family planning counseling and services. But incentives are powerful. Implementing PBI requires careful design and ongoing monitoring in order to avoid unintended consequences. Excluding FP from PBI schemes is not necessarily the solution; doing so can result in its neglect relative to other incentivized health indicators. Given the central role FP plays in attainment of the Millennium Development Goals, appropriate mechanisms to incorporate FP into PBI approaches are needed.
How Do PBI Schemes Work?
PBI schemes can be employed on both the demand and supply sides. Households or patients may be paid for attending health education sessions that include counseling on family planning or reimbursed and/or private hospitals and health centers) may be paid on the basis of the quantity and quality of family planning counseling and other services delivered to the population they serve. Facility teams typically decide how to spend their performance payments, which empowers them to think creatively about how to reward staff, improve facilities, and reach their community through enhanced outreach efforts.
PBI can be implemented at all levels. Incentives can be paid to community health workers (CHWs), health facilities, and sub-national levels of government. Some donors condition aid to national governments on performance. In less stable settings, or where health infrastructure is minimal or weak, PBI schemes are increasingly being used to contract NGOs to increase health service access and build the capacity of local institutions to manage the health system.
Country Experience Mixing PBI with Family Planning
Many PBI schemes in developing countries – some mature and others in the early phases of design or implementation – are currently rewarding improved FP results. For example, in Kenya, Uganda, and Pakistan, women may purchase vouchers at highly subsidized rates that enable them to access FP services at private and/or public facilities. In some countries, such as Burundi and Haiti [PDF, 283KB], NGOs are contracted to provide services and rewarded to reduce FP discontinuation, increase FP utilization and, in some cases, improve the quality of services. In other countries such as the Democratic Republic of the Congo, Egypt, Rwanda [PDF, 299KB], and Zambia, public sector facility teams receive bonuses when FP measures such as new and continuing FP use are achieved. In a few cases, fiscal transfers from national to sub-national levels of government are linked to FP performance ( Argentina and Brazil) and funding from donors to countries is partly conditioned on FP results (regional initiative in Central America and Mexico, and India).
PBI schemes that reward CHWs are growing in popularity. In India and the Philippines, CHWs receive payments for ensuring that women receive a comprehensive package of maternal health services that includes FP counseling. Because CHWs are able to reach rural areas, the incentives help ensure health services are offered where clinics may not be available.
Potential Pitfalls – And How to Avoid Them
Program designers must ensure PBI programs that incorporate family planning are well thought out and carefully implemented. Things to consider about mixing PBI with voluntary family planning include:
- Providers may focus on rewarded services and neglect other important services. PBI schemes that leave out FP may find that providers neglect provision of voluntary FP services, contributing to stagnating FP use, while the use of other rewarded services rises.Poorly designed PBI incentives may result in excessive attention to increasing voluntary FP use, resulting in coercive behavior by managers and providers that interferes with voluntary choice by clients.Without clear communication, clients may incorrectly interpret the offer to cover transportation costs to access counseling or specific services (e.g., voluntary sterilization) as payment to accept a method.
- The quality of information systems may be compromised as the incentives to report the FP results for which providers are rewarded may encourage them to falsify reported information.
Because incentives can be a potentially powerful tool, it is critical to consider the purpose of the incentives, as well as the type of incentive and its size, and to monitor their impact. Pitfalls can be mitigated with smart design and ongoing monitoring and assessment of both intended and unintended effects. Including voluntary FP within a USAID-supported PBI program can be acceptable if it takes care to ensure compliance with the 1998 Tiahrt Amendment and respects voluntarism and informed choice
of FP services. This has been done successfully in a number of cases. Understanding these rules and the history behind them is relevant to all who wish to protect voluntarism.
Best Practices to Consider When Including Voluntary FP in PBI Programs:
“Dos and Don’ts”
Individual client level:
- Do consider offering clients the opportunity to purchase coupons/vouchers (at full or subsidized prices) for a package of services that includes FP. Client payments for the purchase of vouchers promote voluntary FP choice and acceptance and can enable clients to receive services from providers they prefer, either public or private. Do consider reducing financial barriers for voluntary sterilization clients to make the method readily accessible
by subsidizing the cost of the procedure or offering reasonable compensation or in-kind support to those experiencing high service delivery costs, lost wages during convalescence, high transportation costs to reach a facility, or who require food during confinement.
Do consider offering compensation to offset the costs of transportation to enable clients to attend health
education sessions and to receive FP counseling.Do include attendance in health education sessions that discuss FP as one of the conditions of CCT programs. Don’t pay clients or give them any benefits in exchange for accepting a method.
- Don’t deny clients a benefit if they choose not to accept FP.
Individual health worker level:
- Do consider paying health providers for FP services that include quality counseling as well as provision of a
method. Payment should be reasonable, where “reasonable” implies payments that are in line with payments for other services. This includes compensation for services delivered to voucher clients.
Don’t reward health providers for achieving a target number of FP users or users of a particular FP method.
- Don’t compensate for delivery of specific FP methods with payments that are out of line with payments for
other services, as this may lead to coercive behavior.
Health facility, health team, or NGO level:
- Do consider rewarding the availability of a wide range of methods. Do consider rewarding facilities or teams to attain performance objectives. Health facility or team targets or
goals should not be distributed to health care providers as individual targets. Consider rewarding facilities or
teams to attain performance objectives specified as number of clients counseled, or number of new FP clients
accepting FP methods. Please note: health facilities and teams have more than one health worker. For facilities
with one health worker, refer to the guidelines for individual health workers.
Do include FP counseling as a component of antenatal and postnatal care indicators. Do reward performance indicators that combine FP services provided and measures of FP quality.
- Don’t compensate for delivery of specific FP methods with payments that are out of line with payments for
other services, as this may lead to coercive behavior.
Sub-national or national level:
- Do consider opportunities to link fiscal transfers from national to sub-national levels of government to results related to population coverage of specific methods, counseling and education, improved quality, and increased access.
Source: Eichler, Rena, Barbara Seligman, Alix Beith and Jenna Wright. September 2010. Performance-based Incentives: Ensuring Voluntarism in Family Planning Initiatives. Bethesda, MD: Health Systems 20/20 project, Abt Associates Inc. http://www.healthsystems2020.org/content/resource/detail/2686/. |
Learn more
|
 |
| |
|
- A recent publication, Performance-Based Incentives: Ensuring Voluntarism in Family Planning Initiatives, identifies the opportunities and challenges of incorporating FP into PBI approaches. The paper discusses U.S. policies and support for enhancing access to FP and presents what is known about how low- and middle-income countries are including FP in PBI schemes. It also provides suggestions and best practices for donors, policymakers, program implementers, and technical assistance providers to consider when seeking to responsibly and effectively integrate voluntary FP into PBI programs in the developing world.
- The USAID Web site provides links to the policy language that governs the use of FP assistance and outlines USAID’s guiding principles. Two essential documents are also available on this Web site: Guidance for Implementing the ‘Tiahrt’ Requirements for Voluntary Family Planning Projects [PDF, 47KB] and Technical Guidance on the ‘Comprehensible Information’ Paragraph of the Tiahrt Clause [PDF, 139KB].
USAID’s Global Health E-Learning Center also includes a publicly available e-learning course on all U.S. FP requirements, including the Tiahrt Amendment.
- Performance Incentives for Global Health: Potential and Pitfalls, a book from the Center for Global Development, takes stock of a growing set of international experiences with pay for performance. The book includes country-specific case studies from Afghanistan, Haiti, Nicaragua, Rwanda, and the United States; a regional case study from Latin America on cash transfers; and a case on use of incentives for tuberculosis diagnosis and treatment worldwide. See accompanying video.
- Health Systems 20/20 has recently developed a primer on PBI for USAID Missions that describes how to use incentives to improve health service delivery and health outcomes, and a Blueprint Guide, which assists countries designing country-specific PBI schemes. The Health Systems 20/20 Web site also includes a PBI case study series and a collection of country-specific PBI tools (such as sample contracts, guidance on how to determine payment recipients, and sample indicators) that can help inform countries interested in introducing performance-based incentives.
- Visit the World Bank’s Results-Based Financing Web site, which includes an RBF knowledge library and information on the Bank’s multidonor Health Results Innovation Trust Fund (HRITF). The HRITF finances activities to enhance access to and improve the quality of basic health services using a variety of RBF mechanisms. HRITF currently supports activities in Afghanistan, Benin, the Democratic Republic of the Congo, Ghana, India, Kyrgyz Republic, Rwanda, Zambia, and Zimbabwe.
¹ See Eichler and Levine, “Performance Incentives for Global Health: Potential and Pitfalls,” CGD Brief, June 2009, http://www.cgdev.org/content/publications/detail/1422178.
We Want to Tell Your Repositioning Story
Please contact Carmen Coles at ccoles@usaid.gov with your successes in family planning programming.
For more information on Repositioning Family Planning, please contact Alexandra Todd-Lippock at atoddlippock@usaid.gov or Carmen Coles at ccoles@usaid.gov.
Prefer French?
If you prefer to receive the French version of this e-Bulletin, please visit your subscriptions page.
Subscribe | Unsubscribe | Update Your E-mail Address | Other USAID E-Newsletters | Privacy Policy
If you have questions or problems with the subscription service, please contact support@govdelivery.com.
|
