Long-term effects of payment for performance on maternal and child health outcomes: evidence from Tanzania.

BACKGROUND: The success of payment for performance (P4P) schemes relies on their ability to generate sustainable changes in the behaviour of healthcare providers. This paper examines short-term and longer-term effects of P4P in Tanzania and the reasons for these changes. METHODS: We conducted a controlled before and after study and an embedded process evaluation. Three rounds of facility, patient and household survey data (at baseline, after 13 months and at 36 months) measured programme effects in seven intervention districts and four comparison districts. We used linear difference-in-difference regression analysis to determine programme effects, and differential effects over time. Four rounds of qualitative data examined evolution in programme design, implementation and mechanisms of change. RESULTS: Programme effects on the rate of institutional deliveries and antimalarial treatment during antenatal care reduced overtime, with stock out rates of antimalarials increasing over time to baseline levels. P4P led to sustained improvements in kindness during deliveries, with a wider set of improvements in patient experience of care in the longer term. A change in programme management and funding delayed incentive payments affecting performance on some indicators. The verification system became more integrated within routine systems over time, reducing the time burden on managers and health workers. Ongoing financial autonomy and supervision sustained motivational effects in those aspects of care giving not reliant on funding. CONCLUSION: Our study adds to limited and mixed evidence documenting how P4P effects evolve over time. Our findings highlight the importance of undertaking ongoing assessment of effects over time.

Pay-for-performance reduces bypassing of health facilities: Evidence from Tanzania.

Many patients and expectant mothers in low-income countries bypass local health facilities in search of better-quality services. This study examines the impact of a payment-for-performance (P4P) scheme on bypassing practices among expectant women in Tanzania. We expect the P4P intervention to reduce incidences of bypassing by improving the quality of services in local health facilities, thereby reducing the incentive to migrate. We used a difference-in-difference regression model to assess the impact of P4P on bypassing after one year and after three years. In addition, we implemented a machine learning approach to identify factors that predict bypassing. Overall, 38% of women bypassed their local health service provider to deliver in another facility. Our analysis shows that the P4P scheme significantly reduced bypassing. On average, P4P reduced bypassing in the study area by 17% (8 percentage points) over three years. We also identified two main predictors of bypassing - facility type and the distance to the closest hospital. Women are more likely to bypass if their local facility is a dispensary instead of a hospital or a health center. Women are less likely to bypass if they live close to a hospital.

Effectiveness of a girls' empowerment programme on early childbearing, marriage and school dropout among adolescent girls in rural Zambia: study protocol for a cluster randomized trial.

BACKGROUND: Adolescent pregnancies pose a risk to the young mothers and their babies. In Zambia, 35% of young girls in rural areas have given birth by the age of 18 years. Pregnancy rates are particularly high among out-of-school girls. Poverty, low enrolment in secondary school, myths and community norms all contribute to early childbearing. This protocol describes a trial aiming to measure the effect on early childbearing rates in a rural Zambian context of (1) economic support to girls and their families, and (2) combining economic support with a community intervention to enhance knowledge about sexual and reproductive health and supportive community norms. METHODS/DESIGN: This cluster randomized controlled trial (CRCT) will have three arms. The clusters are rural schools with surrounding communities. Approximately 4900 girls in grade 7 in 2016 will be recruited from 157 schools in 12 districts. In one intervention arm, participating girls and their guardians will be offered cash transfers and payment of school fees. In the second intervention arm, there will be both economic support and a community intervention. The interventions will be implemented for approximately 2 years. The final survey will be 4.5 years after recruitment. The primary outcomes will be "incidence of births within 8 months of the end of the intervention period", "incidence of births before girls' 18th birthday" and "proportion of girls who sit for the grade 9 exam". Final survey interviewers will be unaware of the intervention status of respondents. Analysis will be by intention-to-treat and adjusted for cluster design and confounders. Qualitative process evaluation will be conducted. DISCUSSION: This is the first CRCT to measure the effect of combining economic support with a community intervention to prevent adolescent childbearing in a low- or middle-income country. We have designed a programme that will be sustainable and feasible to scale up. The findings will be relevant for programmes for adolescent reproductive health in Zambia and similar contexts. TRIAL REGISTRATION: ISRCTN registry: ISRCTN12727868 , (4 March 2016).

Effect of Paying for Performance on Utilisation, Quality, and User Costs of Health Services in Tanzania: A Controlled Before and After Study.

BACKGROUND: Despite widespread implementation across Africa, there is limited evidence of the effect of payment for performance (P4P) schemes in low income countries on the coverage of quality services and affordability, consistent with universal health coverage objectives. We examined the effect of a government P4P scheme on utilisation, quality, and user costs of health services in Tanzania. METHODS: We evaluated the effects of a P4P scheme on utilisation of all maternal and child immunization services targeted by the scheme, and non-targeted general outpatient service use. We also evaluated effects on patient satisfaction with care and clinical content of antenatal care, and user costs. The evaluation was done in 150 facilities across all 7 intervention districts and 4 comparison districts with two rounds of data collection over 13-months in January 2012 and February 2013. We sampled 3000 households of women who had delivered in the 12 months prior to interview; 1500 patients attending health facilities for targeted and non-targeted services at each round of data collection. Difference-in-difference regression analysis was employed. FINDINGS: We estimated a significant positive effect on two out of eight targeted indicators. There was an 8.2% (95% CI: 3.6% to 12.8%) increase in coverage of institutional deliveries among women in the intervention area, and a 10.3% (95% CI: 4.4% to 16.1%) increase in the provision of anti-malarials during pregnancy. Use of non-targeted services reduced at dispensaries by 57.5 visits per month among children under five (95% CI: -110.2 to -4.9) and by 90.8 visits per month for those aged over five (95% CI: -156.5 to -25.2). There was no evidence of an effect of P4P on patient experience of care for targeted services. There was a 0.05 (95% CI: 0.01 to 0.10) increase in the patient satisfaction score for non-targeted services. P4P was associated with a 5.0% reduction in those paying out of pocket for deliveries (95% CI: -9.3% to -0.7%) but there was no evidence of an effect on the average amount paid. CONCLUSION: This study adds to the very limited evidence on the effects of P4P at scale and highlights the potential risks of such schemes in relation to non-targeted service use. Further consideration of the design of P4P schemes is required to enhance progress towards universal health coverage, and close monitoring of effects on non-targeted services and user costs should be encouraged.

Why don't clinicians adhere more consistently to guidelines for the Integrated Management of Childhood Illness (IMCI)?

The Integrated Management of Childhood Illness (IMCI) has been introduced to reduce child morbidity and mortality in countries with a poor health infrastructure. Previous studies have documented a poor adherence to clinical guidelines, but little is known about the reasons for non-adherence. This mixed-method study measures adherence to IMCI case-assessment guidelines and identifies the reasons for weak adherence. In 2007, adherence was measured through direct observation of 933 outpatient consultations performed by 103 trained clinicians in 82 health facilities in nine districts in rural Tanzania, while clinicians' knowledge of the guidelines was assessed through clinical vignettes. Other potential reasons for a weak adherence were assessed through both a health worker- and health facility survey, as well as by a qualitative follow-up study in 2009 in which in-depth interviews were conducted with 40 clinicians in 30 health facilities located in two of the same districts. Clinicians performed 28.4% of the relevant IMCI assessment tasks. The level of knowledge was considerably higher than actual performance, suggesting that lack of knowledge is not the only constraint for improved performance. Other important reasons for weak performance seem to be 1) lack of motivation to adhere to IMCI guidelines, stemming partly from a weak belief in the importance of following the guidelines and partly from weak intrinsic motivation, and 2) a physical and/or cognitive "overload", resulting in lack of capacity to concentrate fully on each and every case and a resort to simpler rules of thumb. Poor remunerations contribute to several of these factors.

Lifetime QALY prioritarianism in priority setting: quantification of the inherent trade-off.

BACKGROUND: Multiple principles are relevant in priority setting, two of which are often considered particularly important. According to the greater benefit principle, resources should be directed toward the intervention with the greater health benefit. This principle is intimately linked to the goal of health maximization and standard cost-effectiveness analysis (CEA). According to the worse off principle, resources should be directed toward the intervention benefiting those initially worse off. This principle is often linked to an idea of equity. Together, the two principles accord with prioritarianism; a view which can motivate non-standard CEA. Crucial for the actual application of prioritarianism is the trade-off between the two principles, and this trade-off has received scant attention when the worse off are specified in terms of lifetime health. This paper sheds light on that specific trade-off and on the public support for prioritarianism by providing fresh empirical evidence and by clarifying the close links between the findings and normative theory. METHODS: A new, self-administered, computer-based questionnaire was used, to which 96 students in Norway responded. How respondents wanted to balance quality-adjusted life years (QALYs) gained against benefiting those with few lifetime QALYs was quantified for a range of different cases. RESULTS: Respondents supported both principles and were willing to make trade-offs in a particular way. In the baseline case, the median response valued a QALY 3.3 and 2.5 times more when benefiting someone with lifetime QALYs of 10 and 25 rather than 70. Average responses harbored fundamental disagreements and varied modestly across distributional settings. CONCLUSION: In the specific context of lifetime health, the findings underscore the insufficiency of pure QALY maximization and explicate how people make trade-offs in a way that can help operationalize lifetime prioritarianism and non-standard CEA. Seen through the lens of normative theory, the findings highlight key challenges for prioritarianism applied to priority setting.

Using incentives to attract nurses to remote areas of Tanzania: a contingent valuation study.

This article analyses (1) how financial incentives (salary top-ups) and non-financial incentives (housing and education) affect nurses' willingness to work in remote areas of Tanzania and (2) how the magnitude of the incentives needed to attract health workers varies with the nurses' geographic origin and their intrinsic motivation. A contingent valuation method was used to elicit the location preferences of 362 nursing students. Without any interventions, 19% of the nurses were willing to work in remote places. With the provision of free housing, this share increased by 15 percentage points. Better education opportunities increased the share by 28 percentage points from the baseline. For a salary top-up to have the same effect as provision of free housing, the top-up needs to be between 80 and 100% of the base salary. Similarly, for salary top-ups to have the same effect as provision of better education opportunities, the top-up should be between 120 and 140%. Our study confirms results from previous research, that those with a strong intrinsic motivation to provide health care are more motivated to work in a remote location. A more surprising finding is that students of older age are more prepared to take a job in remote areas. Several studies have found that individuals who grew up in a remote area are more willing to work in such locations. A novel finding of our analysis is that only nursing students with a 'very' remote origin (i.e. those who grew up farther from a district centre than the suggested remote working place) express a higher willingness to take the remote job. Although we do control for nursing school effects, our results could be biased due to omitted variables capturing individual characteristics.

Protocol for the evaluation of a pay for performance programme in Pwani region in Tanzania: a controlled before and after study.

BACKGROUND: The use of supply-side incentives to increase health service utilisation and enhance service quality is gaining momentum in many low- and middle-income countries. However, there is a paucity of evidence on the impact of such schemes, their cost-effectiveness, and the process of implementation and potential unintended consequences in these settings. A pay for performance (P4P) programme was introduced in Pwani region of Tanzania in 2011. METHODS/DESIGN: An evaluation of the programme will be carried out to inform a potential national rollout. A controlled before and after study will examine the effect of the P4P programme on quality, coverage, and cost of targeted maternal and newborn healthcare services and selected non-targeted services at facilities in Tanzania. Data will be collected from a survey of 75 facilities, 750 patients exiting consultations, over 75 health workers, and 1,500 households of women who delivered in the previous year, in all seven intervention districts. Data will be collected from the same number of respondents in four control districts. A process evaluation will examine: whether the P4P programme was implemented as planned; stakeholder response to the programme and its acceptability; and implementation bottlenecks and facilitating factors. Three rounds of process data collection will be conducted including a review of available P4P documents, individual interviews and focus group discussions with key informants working at facility and district level in five of the intervention districts, and at the regional and national levels. An economic evaluation will measure the cost-effectiveness of P4P relative to current practice from a societal perspective. DISCUSSION: This evaluation will contribute robust evidence on the impact and cost-effectiveness of P4P in a low income setting, as well as generate a better understanding of the feasibility of integrating complex intervention packages like P4P within health systems in resource poor settings.

A universal preference for equality in health? Reasons to reconsider properties of applied social welfare functions.

The literature on how to combine efficiency and equity considerations in the social valuation of health allocations has borrowed extensively from applied welfare economics, including the literature on inequality measurement. By so doing, it has adopted normative assumptions that have been applied for evaluating the allocation of welfare (or income) rather than the allocation of health, including the assumption of a monotonically declining social marginal value of welfare/income/health. At the same time, empirical studies that have elicited social preferences for allocation of health have reported results that are seemingly incompatible with this assumption. There are two ways of addressing this inconsistency; we may censor the stated preferences by arguing that they cannot be supported by normative arguments, or we may reject or modify the analytical framework in order to accommodate the stated preferences. We argue that the stated preferences can be supported by normative reasoning and therefore conclude that one should be cautious in applying the standard welfare economic framework to the allocation of health.

The decision to vaccinate a child: an economic perspective from southern Malawi.

The dynamics of childhood vaccination uptake in developing countries are unclear. Numerous studies document the relationship between vaccination coverage and access, socio economic and demographic factors. However, there is less knowledge about the relationship between vaccination coverage and carers' motivation and willingness to seek childhood vaccinations. The aim of this paper is to introduce a framework for studying demand for childhood vaccination and to examine the coherence between theoretical predictions and empirical findings in a rural area in Malawi. We interviewed 635 carers with children aged 18-59 months. About 96 percent of the respondents reported to have fully vaccinated their youngest eligible child for all routine vaccinations scheduled in the Expanded Program on Immunization. This paper concludes that easy access to vaccination services cannot explain why demand is high. Many carers had to travel long distances to reach vaccination delivery points and a considerable share of the respondents scored waiting and travelling time as long. Results from the present study, in combination with theoretical predictions, suggest that a high level of trust in distributors of information and vaccines may be an essential explanatory factor for why carers seek immunization for their children, even in the presence of considerable costs. Trust may be an important explanatory factor as it can be seen to generate positive perceived benefits.

Informal payments and the quality of health care: Mechanisms revealed by Tanzanian health workers.

Informal payments for health services are common in many transitional and developing countries. The aim of this paper is to investigate the nature of informal payments in the health sector of Tanzania and to identify mechanisms through which informal payments may affect the quality of health care. Our focus is on the effect of informal payments on health worker behaviours, in particular the interpersonal dynamics among health workers at their workplaces. We organised eight focus groups with 58 health workers representing different cadres and levels of care in one rural and one urban district in Tanzania. We found that health workers at all levels receive informal payments in a number of different contexts. Health workers sometimes share the payments received, but only partially, and more rarely within the cadre than across cadres. Our findings indicate that health workers are involved in 'rent-seeking' activities, such as creating artificial shortages and deliberately lowering the quality of service, in order to extract extra payments from patients or to bargain for a higher share of the payments received by their colleagues. The discussions revealed that many health workers think that the distribution of informal payments is grossly unfair. The findings suggest that informal payments can impact negatively on the quality of health care through rent-seeking behaviours and through frustrations created by the unfair allocation of payments. Interestingly, the presence of corruption may also induce non-corrupt workers to reduce the quality of care. Positive impacts can occur because informal payments may induce health workers to increase their efforts, and maybe more so if there is competition among health workers about receiving the payments. Moreover, informal payments add to health workers' incomes and might thus contribute to retention of health workers within the health sector.

Overworked? On the relationship between workload and health worker performance.

The shortage of health workers in many low-income countries poses a threat to the quality of health services. When the number of patients per health worker grows sufficiently high, there will be insufficient time to diagnose and treat all patients adequately. This paper tests the hypothesis that high caseload reduces the level of effort per patient in the diagnostic process. We observed 159 clinicians in 2095 outpatient consultations at 126 health facilities in rural Tanzania. Surprisingly, we find no association between caseload and the level of effort per patient. Clinicians appear to have ample amounts of idle time. We conclude that health workers are not overworked and that scaling up the number of health workers is unlikely to raise the quality of health services. Training has a positive effect on quality but is not in itself sufficient to raise quality to adequate levels.

The decentralisation-centralisation dilemma: recruitment and distribution of health workers in remote districts of Tanzania.

BACKGROUND: The implementation of decentralisation reforms in the health sector of Tanzania started in the 1980s. These reforms were intended to relinquish substantial powers and resources to districts to improve the development of the health sector. Little is known about the impact of decentralisation on recruitment and distribution of health workers at the district level. Reported difficulties in recruiting health workers to remote districts led the Government of Tanzania to partly re-instate central recruitment of health workers in 2006. The effects of this policy change are not yet documented. This study highlights the experiences and challenges associated with decentralisation and the partial re-centralisation in relation to the recruitment and distribution of health workers. METHODS: An exploratory qualitative study was conducted among informants recruited from five underserved, remote districts of mainland Tanzania. Additional informants were recruited from the central government, the NGO sector, international organisations and academia. A comparison of decentralised and the reinstated centralised systems was carried out in order to draw lessons necessary for improving recruitment, distribution and retention of health workers. RESULTS: The study has shown that recruitment of health workers under a decentralised arrangement has not only been characterised by complex bureaucratic procedures, but by severe delays and sometimes failure to get the required health workers. The study also revealed that recruitment of highly skilled health workers under decentralised arrangements may be both very difficult and expensive. Decentralised recruitment was perceived to be more effective in improving retention of the lower cadre health workers within the districts. In contrast, the centralised arrangement was perceived to be more effective both in recruiting qualified staff and balancing their distribution across districts, but poor in ensuring the retention of employees. CONCLUSION: A combination of centralised and decentralised recruitment represents a promising hybrid form of health sector organisation in managing human resources by bringing the benefits of two worlds together. In order to ensure that the potential benefits of the two approaches are effectively integrated, careful balancing defining the local-central relationships in the management of human resources needs to be worked out.

Eliciting people's preferences for the distribution of health: A procedure for a more precise estimation of distributional weights.

In order to incorporate distributional concerns into cost-effectiveness analysis, it would be useful to elicit distributional weights that express people's valuation of marginal health gains at various levels of health. Distributional preferences are commonly elicited either through a person trade off (PTO) or a gain trade off (GTO) technique. An inherent problem of the GTO is that it is based on the valuation of non-marginal health gains. In practice, many contributions using the PTO also focus on non-marginal health gains. This paper demonstrates that the failure to distinguish appropriately between marginal and non-marginal health gains may lead to seriously misleading estimates of distributional weights. Moreover, the paper proposes a methodology for utilising information obtained through non-marginal analysis more efficiently in order to obtain more reliable estimates of distributional weights. The methodology was successfully applied in an empirical study of age weights.

Measuring inequalities in the distribution of health workers: the case of Tanzania.

BACKGROUND: The overall human resource shortages and the distributional inequalities in the health workforce in many developing countries are well acknowledged. However, little has been done to measure the degree of inequality systematically. Moreover, few attempts have been made to analyse the implications of using alternative measures of health care needs in the measurement of health workforce distributional inequalities. Most studies have implicitly relied on population levels as the only criterion for measuring health care needs. This paper attempts to achieve two objectives. First, it describes and measures health worker distributional inequalities in Tanzania on a per capita basis; second, it suggests and applies additional health care needs indicators in the measurement of distributional inequalities. METHODS: We plotted Lorenz and concentration curves to illustrate graphically the distribution of the total health workforce and the cadre-specific (skill mix) distributions. Alternative indicators of health care needs were illustrated by concentration curves. Inequalities were measured by calculating Gini and concentration indices. RESULTS: There are significant inequalities in the distribution of health workers per capita. Overall, the population quintile with the fewest health workers per capita accounts for only 8% of all health workers, while the quintile with the most health workers accounts for 46%. Inequality is perceptible across both urban and rural districts. Skill mix inequalities are also large. Districts with a small share of the health workforce (relative to their population levels have an even smaller share of highly trained medical personnel. A small share of highly trained personnel is compensated by a larger share of clinical officers (a middle-level cadre) but not by a larger share of untrained health workers. Clinical officers are relatively equally distributed. Distributional inequalities tend to be more pronounced when under-five deaths are used as an indicator of health care needs. Conversely, if health care needs are measured by HIV prevalence, the distributional inequalities appear to decline. CONCLUSION: The measure of inequality in the distribution of the health workforce may depend strongly on the underlying measure of health care needs. In cases of a non-uniform distribution of health care needs across geographical areas, other measures of health care needs than population levels may have to be developed in order to ensure a more meaningful measurement of distributional inequalities of the health workforce.

Distribution matters: equity considerations among health planners in Tanzania.

BACKGROUND: Maximising health as the guiding principle for resource allocation in health has been challenged by concerns about the distribution of health outcomes. There are few empirical studies that consider these potentially divergent objectives in settings of extreme resource scarcity. The aim of this study is to help fill this knowledge gap by exploring distributional preferences among health planners in Tanzania. METHODS: A deliberative group method was employed. Participants were health planners at district and regional level, selected by strategic sampling. The health planners alternated between group discussion and individual tasks. Respondents ranked health programmes with different target groups, and selected and ranked the reasons they thought should be given most importance in priority setting. RESULTS: A majority consistently assigned higher rankings to programmes where the initial life expectancy of the target group was lower. A high proportion of respondents considered "affect those with least life expectancy" to be the most important reason in priority setting. CONCLUSIONS: Distribution of health outcomes, in terms of life-years, matters. Specifically, the lower the initial life expectancy of the target group, the more important the programme is considered. Such preferences are compatible, within the sphere of health, with what ethicists call "prioritarianism".