Stunted scale-up of a performance-based financing program on HIV and maternal-child health services in Mozambique - a policy analysis.

OBJECTIVE: A performance-based financing (PBF) program was implemented for services for HIV, prevention of mother-to-child transmission (PMTCT) and maternal/child health (MCH) in two provinces of Mozambique. This study investigates the determinants of policy scale-up to help accelerate the expansion of PBF in Mozambique and globally from pilot projects to national policies. METHODS: A retrospective policy programme analysis was carried out using in-depth key informant interviews. A total of 24 interviews were conducted with stakeholders from donor agencies, the implementing NGO, district and provincial health offices, and the Ministry of Health. RESULTS: Stakeholders reported that the scale-up process of PBF was influenced by three key determinants: political power, financial sustainability, and available capacity and evidence. In Mozambique, PBF scaled-up provincially but not nationally due to these determinants. The adoption of PBF in Mozambique involved a restricted range of policy actors at the central level and was strongly driven by the donor and a PBF champion. Provincial scale-up was fostered by political support and increasing capacity over time. CONCLUSION: There was a generalised ambivalence and lack of incentive to scale-up PBF from the implementing NGO. Coupled with the lack of evidence of a positive effect, and of cost-effectiveness in comparison with other models to improve health service delivery and health system strengthening, it is difficult to argue for the need to scale up the PBF programme studied. Care needs to be taken to base the adoption of health policies, including PBF, on a situational analysis and on evidence of intervention effectiveness, cost-benefits and contextual fit.

Performance-based financing kick-starts motivational "feedback loop": findings from a process evaluation in Mozambique.

BACKGROUND: Performance-based financing (PBF) reforms aim to directly influence health worker behavior through changes to institutional arrangements, accountability structures, and financial incentives based on performance. While there is still some debate about whether PBF influences extrinsic or intrinsic motivators, recent research finds that PBF affects both. Against this backdrop, our study presents findings from a process evaluation of a PBF program in Mozambique, exploring the perceived changes to both internal and external drivers of health worker motivation associated with PBF. METHODS: We used a qualitative research design with in-depth, semi-structured interviews with health workers, which included a rank order exercise and focus group discussions. Interviews were analyzed by two researchers using thematic analysis techniques. Rank order frequency was calculated using weighted average methodology. RESULTS: Health workers reported that PBF, overall, positively influenced their motivation by introducing or reinforcing both internal and external motivational drivers. Internal drivers included enhanced self-efficacy driven by goal orientation, healthy competition among colleagues, and job satisfaction. External drivers included an organized work environment, enhanced access to equipment and supplies, financial incentives, teamwork, and regular consultations with verifiers (a type of supervision). PBF stimulates an interactive relationship between internal and external motivational drivers, creating a feedback loop involving responsibility, achievement, and recognition, which increased perceived motivation. CONCLUSIONS: The PBF program helped workers feel that they had well-defined and achievable goals and that they received recognition from verification teams, management committees, and colleagues due to enhanced accountability and governance. Our paper shows that financial incentives could serve as the "driver" to kick-start the feedback loop, of responsibility, achievement, and recognition, in environments that lack other drivers. Understanding how PBF programs can be designed and refined to reinforce this feedback loop could be a powerful tool to further enhance and track positive motivational changes. For countries thinking about PBF, we recommend that policymakers assess the loop in their contexts, identify drivers, determine whether these drivers are sufficient, and consider PBF if they are not. TRIAL REGISTRATION: We obtained ethical approval for the study protocol, data collection instruments, and informed consent forms from the Ethics Review Committee of the Centers for Disease Control and Prevention (CDC) [IRB 2015-190] and the Ethics Review Committee of the Mozambique Ministry of Health.

The effect of a performance-based financing program on HIV and maternal/child health services in Mozambique-an impact evaluation.

Performance-based financing (PBF) is a mechanism by which health providers are paid on the basis of outputs or results delivered. A PBF program was implemented on the provision of HIV, prevention of mother-to child HIV transmission (PMTCT), and maternal/child health (MCH) services in two provinces of Mozambique. A retrospective case-control study design was used in which PBF provinces were matched with control provinces to evaluate the impact of PBF on 18 indicators. Due to regional heterogeneity, we evaluated the intervention sites (North and South) separately. Beginning January 2011, 11 quarters (33 months or 2.75 years) of data from 134 facilities after matching (84 in the North and 50 in the South) were used. Our econometric framework employed a multi-period, multi-group difference-in-differences model on data that was matched using propensity scoring. The regression design employed a generalized linear mixed model with both fixed and random effects, fitted using the seemingly unrelated regression technique. PBF resulted in positive impacts on MCH, PMTCT and paediatric HIV program outcomes. The majority of the 18 indicators responded to PBF (77% in the North and 66% in the South), with at least half of the indicators demonstrating a statistically significant increase in average output of more than 50% relative to baseline. Excluding pregnant women, the majority of adult HIV treatment indicators did not respond to PBF. On average, it took 18 months (six quarters) of implementation for PBF to take effect, and impact was generally sustained thereafter. Indicators were not sensitive to price, but were inversely correlated to the level of effort associated with marginal output. No negative impacts on incentivized indicators nor spill-over effects on non-incentivized indicators were observed. The PBF program in Mozambique has produced large, sustained increases in the provision of PMTCT, paediatric HIV and MCH services. Our results demonstrate that PBF is an effective strategy for driving down the HIV epidemic and advancing MCH care service delivery as compared with input financing alone.

A Global Perspective on Cardiovascular Disease in Vulnerable Populations.

Cardiovascular disease (CVD) is a major contributor to the growing public health epidemic in chronic diseases. Much of the disease and disability burden from CVDs are in people younger than the age of 70 years in low- and middle-income countries, formerly "the developing world." The risk of CVD is heavily influenced by environmental conditions and lifestyle variables. In this article we review the scope of the CVD problem in low- and middle-income countries, including economic factors, risk factors, at-risk groups, and explanatory frameworks that hypothesize the multifactorial drivers. Finally, we discuss current and potential interventions to reduce the burden of CVD in vulnerable populations including research needed to evaluate and implement promising solutions for those most at risk.

Does household enrolment reduce adverse selection in a voluntary health insurance system? Evidence from the Ghanaian National Health Insurance System.

In August 2003, the Ghanaian Government made history by implementing the first National Health Insurance System (NHIS) in sub-Saharan Africa. Within 2 years, over one-third of the country had voluntarily enrolled in the NHIS. To discourage households from selectively enrolling their sickest (high-risk) members, the NHIS in the Nkoranza district offered premium waivers for all children under 18 in exchange for full household enrolment. This study aimed to test whether, despite this incentive, there is evidence suggestive of adverse selection. To accomplish this, we examined how the observed pay-off from insurance (odds and intensity of medical consumption) responds to changes in the family enrolment cost. If adverse selection were present, we would expect the odds and intensity of medical consumption to increase with family enrolment cost. A number of econometric tests were conducted using the claims database of the NHIS in Nkoranza. Households with full enrolment were analysed, for a total of 58 516 individuals from 12 515 households. Our results show that household enrolment cost is not correlated with (1) odds or intensity of inpatient use or (2) odds of adult outpatient use, and is weakly correlated with the intensity of outpatient use. We also find that household enrolment costs are positively correlated with the number of children in the household and the odds and intensity of outpatient use by children. Thus, we conclude that the child-premium waiver is an important incentive for household enrolment. This evidence suggests that adverse selection has effectively been contained, but not eliminated. We argue that since one of the main objectives of the NHIS was to increase use of necessary care, especially by children, our findings indicate a largely favourable policy outcome, but one that may carry negative financial consequences. Policy makers must balance the fiscal need to contain costs with the societal objective to cover vulnerable populations.

The financial protection effect of Ghana National Health Insurance Scheme: evidence from a study in two rural districts.

BACKGROUND: One of the key functions of health insurance is to provide financial protection against high costs of health care, yet evidence of such protection from developing countries has been inconsistent. The current study uses the case of Ghana to contribute to the evidence pool about insurance's financial protection effects. It evaluates the impact of the country's National Health Insurance Scheme on households' out-of-pocket spending and catastrophic health expenditure. METHODS: We use data from a household survey conducted in two rural districts, Nkoranza and Offinso, in 2007, two years after the initiation of the Ghana National Health Insurance Scheme. To address the skewness of health expenditure data, the absolute amount of out-of-pocket spending is estimated using a two-part model. We also conduct a probit estimate of the likelihood of catastrophic health expenditures, defined at different thresholds relative to household income and non-food consumption expenditure. The analysis controls for chronic and self-assessed health conditions, which typically drive adverse selection in insurance. RESULTS: At the time of the survey, insurance coverage was 35 percent. Although the benefit package of insurance is generous, insured people still incurred out-of-pocket payment for care from informal sources and for uncovered drugs and tests at health facilities. Nevertheless, they paid significantly less than the uninsured. Insurance has been shown to have a protective effect against the financial burden of health care, reducing significantly the likelihood of incurring catastrophic payment. The effect is particularly remarkable among the poorest quintile of the sample. CONCLUSIONS: Findings from this study confirm the positive financial protection effect of health insurance in Ghana. The effect is stronger among the poor group than among general population. The results are encouraging for many low income countries who are considering a similar policy to expand social health insurance. Ghana's experience also shows that instituting insurance by itself is not adequate to remove fully the out-of-pocket payment for health. Further works are needed to address the supply side's incentives and quality of care, so that the insured can enjoy the full benefits of insurance.

Economic burden of neurocysticercosis: results from Peru.

Neurocysticercosis (NCC) is a major cause of neurological morbidity in the developing world. This study aimed to assess the treatment costs and productivity losses associated with NCC in Peru. NCC patients were identified through retrospective chart analysis. Patients meeting inclusion criteria were interviewed in order to obtain data on symptom history, treatment costs, productivity losses and health service utilisation patterns. These data were modelled to determine average treatment costs and productivity losses over 2 years. Our findings show that treatment costs and productivity losses consume 54% of an annual minimum wage salary during the first year of treatment and 16% during the second year. Diagnosis (36%) and drug therapy (27%) represent the most expensive healthcare-related costs. These costs are prohibitive for some-8% of our study sample had no diagnostic tests during their first 6 months of disease, and two-thirds of those who delayed treatment reportedly did so due to their inability to pay. Two-thirds of wage-earners lost their jobs owing to NCC and only 61% were able to re-engage in wage-earning activities. This study highlights the need to expand financial coverage to ensure the poor have access to health services and do not become further impoverished.

The costs of interpersonal violence--an international review.

This article reviews evidence of the economic impact of interpersonal violence internationally. In the United States, estimates of the costs of interpersonal violence reach 3.3% of GDP. The public sector-and thus society in general-bears the majority of these costs. Interpersonal violence is defined to include violence between family members and intimate partners, and violence between acquaintances and strangers that is not intended to further the aims of any formally defined group or cause. Although these types of violence disproportionately affect poorer countries, there is a scarcity of studies of their economic impact in these countries. International comparisons are complicated by the calculation of economic losses based on foregone wages and income, thus undervaluing economic losses in poorer countries.