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PBF ToC some reflections


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This ppt presents some reflections on the theories of change of PBF

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PBF ToC some reflections

  1. 1. Some reflections on PBF theory of change and Quality of Care ToC working group (Eric Bigirimana, Peter Eerens, Rena Eichler, Bruno Meessen, Paula Quigley) Improving quality of care measurement of family planning in Performance-Based Financing system Antwerp, September 14, 2017
  2. 2. Starting point: PBF • We have learned a lot about PBF, there is still so much to learn • PBF often works, but sometimes not • Sometimes, a gap between what is planned and what is implemented, but probably not always • PBF ToC: often more complex than initially thought – there may be more prerequisites, contextual factors, some still unidentified…
  3. 3. Starting point: PBF & QoC • QoC is a huge challenge in LMICs • Low QoC affects effectiveness of PBF programs – examples • A major learning agenda for the PBF CoP – this meeting is a first step • With Family Planning, we will only touch some dimensions and determinants of QoC (fine!)
  4. 4. Starting point: QI • Quality Improvement is not just a matter of measuring well (checklist) • It is also (and more fundamentally) about much more: culture, organisational setup, management, resources, processes, behaviors, technology…
  5. 5. Quality Improvement framework (FP) EpidemiologicalCommunicationSocio-cultural Dimension Information sharing Structural/Organizational dimension Technical/ Clinical dimension Relational dimension PERFORMANCE/ Quality of care Environmental Evidence Based Practices/ MedicineBehavioral dimension Work culture Source: Dr Eric Bigirimana, BREGMANS Cons.& Research Design/ Attractiveness BREGMANS Consulting & Research
  7. 7. Definition of RBF • Performance incentives are transfers of money or goods conditional on taking a measurable action or achieving a predetermined performance target. (Rena Eichler 2009) • RBF: A cash payment or non-monetary transfer made to a national or sub-national government, manager, provider, payer or consumer of health services after predefined results have been attained and verified. (Musgrove 2011)
  8. 8. PBF CoP (7/2010) • Performance-Based Financing is a holistic approach with a result orientation defined as financing based on both quantity and quality of service outputs. This approach entails making health facilities autonomous agencies that work for the benefit of health related goals and their staff. The effectiveness can be enhanced by demand-side interventions such as CCTs, vouchers schemes, equity funds and Community Based Health Insurance programs. It is also characterized by multiple performance frameworks for the regulatory functions, the performance purchasing agency and community empowerment. Performance-Based Financing applies market forces but seeks to correct market failures to attain efficiency gains. PBF at the same time aims at cost- containment and a sustainable mix of revenues from cost-recovery, government and international contributions. PBF draws from micro- economic, systems analysis, and public choice and new public management theories. PBF continuously seeks to test these theories through empirical research and rigorous impact evaluations which lead to best practices”
  9. 9. The principal-agent model The principal measures some outputs / process / outcomes , he rewards or sanctions accordingly (Hypothesis: homo oeconomicus) Standard questions : Does it work? If not, does the principal measure the right thing? Does he pay enough? Should the checklist include other indicators?
  10. 10. The principal-agent model + Variation with other behavioural assumptions. (bounded rationality, behavioral economics…) You recognize that there are psychological biases, interpretation issues… Questions : Is the contract and the checklist intelligible by the health staff? Are the incentive structure in line with human behaviours? Would the staff be more responsive to the sanction instrument?...
  11. 11. PBF as ‘glue’ (P-A++) Dimitri Renmans – Dar-e-Salaam 11/2015 PBF as an enforcement mechanism to allows other ToC of the health system to work Examples: - Availability of funds at the frontline (in a fair way) - Accuracy of routine data - Communication about what matters Question: is it possible to get these benefits in a more cost- effective manner?
  12. 12. PBF as ‘yeast’ Jean Claude Taptué (22/9/2016 on the way to Marondera) PBF enables other discrete actions by managers Examples: - A good manager will quickly seize PBF as an instrument to bring its facility/district to a higher level Hypothesis: there are some necessary conditions for PBF to work Questions: what are these conditions? How to favour their emergence, at district and national level?
  13. 13. PBF is probably all of that 1. We must recognise this multiplicity of channels and our relative ignorance on the one which plays the most (or on their interplay). 2. Both our action and research should better recognize this multiplicity of channels
  14. 14. PBF: changes at different levels
  16. 16. PBF to trigger change • A catalyst towards comprehensive health care reform • Questions: study health system effects, focus on the next move → Dar-e-Salaam 11/2015 Meessen, Soucat & Sekabaraga WHO Bulletin 2011
  17. 17. The challenge of changing PBF • PBF is like an operating system: it is a systemic intervention which interacts with the different building blocks of the system • Rigidities to change PBF, to revise indicators • Questions: how can we enhance the use of PBF by its steward and its partners? What are the barriers for updating indicators?
  19. 19. Implications on action The example of quality of care: • If you believe in the Principal-Agent +, you may want to focus on measuring and rewarding a few indicators of quality of care. • If you believe in ‘glue’ & ‘yeast’, you may want to measure and reward as many QoC indicator as possible (long checklist) + build an interface to empower district managers + equip them with (non-PBF) management techniques.
  20. 20. Implications on research • According to the ToC, you will study different interventions • You may focus on different phenomena: – Direction 1 : indicators which capture the conversion of the health facility staff to quality improvement; indicators which impact outcomes. – Direction 2: indicators which captures leadership, action points taken by district managers…
  21. 21. Measuring quality of family planning • Our pre-meeting intuitions: Keep dimensionality under control And thus, focus on key indicators Think “multiple determinants”, And thus, identify them and assess relevance of their measurement as well Acknowledge complexity, political contexts and other unknowns And thus, avoid too restrictive directions Acknowledge variation across contexts And thus, find ToC(s) with best contextual fit QI is also about behavioral change And thus, leave PBF comfort zone and embrace BC Quality and quality perception evolves And thus, map barriers to updating FP indicators So much research remains to be done And thus, all the above should enter agenda for implementation research
  22. 22. Last reflection • Peter: “Health systems are complex systems. Everything is connected: causality goes through many channels. A ToC is actually a reflexive way to navigate this complexity ; a ToC tells as much about ourselves as about the reality under analysis. Our data should trigger action, much more than measure everything”.