Socioeconomic and fiscal returns of expanded investment in immunization: a case for life-course vaccination in Colombia.

Despite the health, societal, and economic benefits of immunization, many countries focus primarily on childhood immunizations and lack robust policies and sufficient resources for immunizations that can benefit populations across the life course. While the benefits of childhood vaccination are well documented, there is limited evidence on the financial and social return on investment that policymakers can use to inform decisions around administering a life-course immunization program. We developed a cost-benefit model from a societal perspective to evaluate the inclusion of 5 vaccines across the life course in Colombia's national immunization program. This model estimated a return of US$1.3 per US$1.0 invested in the first 2 decades, increasing to US$3.9 after 60 years. Primary benefits were productivity gains, followed by fiscal savings and household averted expenditure on health care. Furthermore, vulnerable households are predicted to receive 3.2 times greater income protection than formally employed households under a life-course immunization program. Consequently, there is a potential to reduce Colombia's income inequality and poverty rate by increasing access to immunization for all ages.

How do performance-based financing programmes measure quality of care? A descriptive analysis of 68 quality checklists from 28 low- and middle-income countries.

This paper seeks to systematically describe the length and content of quality checklists used in performance-based financing programmes, their similarities and differences, and how checklists have evolved over time. We compiled a list of supply-side, health facility-based performance-based financing (PBF) programmes in low- and lower middle-income countries based on a document review. We then solicited PBF manuals and quality checklists from implementers and donors of these PBF mechanisms. We entered each indicator from each quality checklist into a database verbatim in English, and translated into English from French where appropriate, and categorized each indicator according to the Donabedian framework and an author-derived categorization. We extracted 8,490 quality indicators from 68 quality checklists across 32 PBF implementations in 28 countries. On average, checklists contained 125 indicators; within the same program, checklists tend to grow as they are updated. Using the Donabedian framework, 80% of indicators were structure-type, 19% process-type, and less than 1% outcome-type. The author-derived categorization showed that 57% of indicators relate to availability of resources, 24% to managing the facility and 17% assess knowledge and effort. There is a high degree of similarity in a narrow set of indicators used in checklists for common service types such as maternal, neonatal and child health. We conclude that performance-based financing offers an appealing approach to targeting specific quality shortfalls and advancing toward the Sustainable Development Goals of high quality coverage. Currently most indicators focus on structural issues and resource availability. There is scope to rationalize and evolve the quality checklists of these programs to help achieve national and global goals to improve quality of care.

Quality of Care in Performance-Based Financing: How It Is Incorporated in 32 Programs Across 28 Countries.

OBJECTIVE: To describe how quality of care is incorporated into performance-based financing (PBF) programs, what quality indicators are being used, and how these indicators are measured and verified. METHODS: An exploratory scoping methodology was used to characterize the full range of quality components in 32 PBF programs, initiated between 2008 and 2015 in 28 low- and middle-income countries, totaling 68 quality tools and 8,490 quality indicators. The programs were identified through a review of the peer-reviewed and gray literature as well as through expert consultation with key donor representatives. FINDINGS: Most of the PBF programs were implemented in sub-Saharan Africa and most were funded primarily by the World Bank. On average, PBF quality tools contained 125 indicators predominately assessing maternal, newborn, and child health and facility management and infrastructure. Indicators were primarily measured via checklists (78%, or 6,656 of 8,490 indicators), which largely (over 90%) measured structural aspects of quality, such as equipment, beds, and infrastructure. Of the most common indicators across checklists, 74% measured structural aspects and 24% measured processes of clinical care. The quality portion of the payment formulas were in the form of bonuses (59%), penalties (27%), or both (hybrid) (14%). The median percentage (of a performance payment) allocated to health facilities was 60%, ranging from 10% to 100%, while the median percentage allocated to health care providers was 55%, ranging from 20% to 80%. Nearly all of the programs included in the analysis (91%, n=29) verified quality scores quarterly (every 3 months), typically by regional government teams. CONCLUSION: PBF is a potentially appealing instrument to address shortfalls in quality of care by linking verified performance measurement with strategic incentives and could ultimately help meet policy priorities at the country and global levels, including the ambitious Sustainable Development Goals. The substantial variation and complexity in how PBF programs incorporate quality of care considerations suggests a need to further examine whether differences in design are associated with differential program impacts.