The document discusses improving incentives in public health systems in low-income countries through an organizational economic analysis. It proposes adopting a health district strategy with a referral hospital, health centers, and a district office to efficiently deliver primary health care in a decentralized manner. However, the low performance of government-owned health facilities may be partly due to issues with institutional arrangements like fixed salaries and a lack of accountability. The document puts forth several propositions, including linking funding to performance, to reform public health systems and give the health district strategy a better chance at success.

1. Getting incentives right
in public health systems
in low-income countries:
an economic perspective
17/12/2008
Bruno Meessen, ITM

2. Content
• Key questions
• Public health services in low-income countries.
• An organisational economic analysis.
• Ten propositions.

3. Do we agree?
• A vision: Health care for all.
• Government has a key role to play in the
health system. Probably also in the provision
of care.
• The health district is an interesting strategy to
implement primary health care in rural areas.

4. The health district
Referral Hospital
Health Centre
District Office
Responsibility Area

5. Do we agree? There are strong arguments
for the health district strategy
• Experience.
• Efficiency:
– No overlap
– Package of activities (allocative efficiency, technical
efficiency)
– Two packages.
– Decentralisation.
• Equity:
– Input.
– Outputs.

6. Do we still agree?
• Performance of government-owned health
facility is low.
• Reasons:
– Lack of financial resources.
– Lack of human resources.
– Poor implementation (health district).
• Our hypothesis: the low performance is also
due to institutional arrangements.

7. Institutional arrangements in place
NHS model:
• Tax-based financing (or donors).
• Line item budget… or per diem.
• MoH, a hierarchical administration; owners of
facilities.
• Civil servants with fix salaries.
• Allocation through planning.
+ Health district arrangement.

8. Assumptions on human behaviour
• There may be lack of information or problem in
terms of capacity, by preferences are
homogenous: everyone is primary health care
minded.
• => No conflict of view: everyone is aligned on
the planner.
• This fully evacuates moral hazards or adverse
selection problem.

9. Monopolies
• Competition: a problem or a solution?
• Return on scale: natural monopolies.
• The solution: benchmark (and enforce).
• Primary health care minded district managers
do it. Not the others.

10. Asymmetries of information
• Between the MoH and its managers.
• Low-powered incentive (fixed salaries). No
career prospect; no fair tournament.
• Result: low creativity, low effort.

11. Package of activities
• = Bundle of tasks.
• Multitasking model.
• A good reason for low-powered incentive.
• Yet, there are some tasks with high-powered
incentives: curative care with user fees.
• Distortion in priorities.

12. What can we do?
• Let us give to our idealism its right place.
• Reform public health systems.
• The health district is a nice strategy. Let us give
it a second chance.
• There is no perfect arrangement: advantages >
disadvantages

13. Propositions
• (1) Money should follow the users.
• (2) Benefits should reach the poor.
• (3) Third party payer.
• (4) Accountability through voice.
• (5) Clearer definitions of performance.
• (6) Input-based ⇒ Performance-based payment.
• (7) More decision rights on process to managers.
• (8) Verification.
• (9) Consolidate other institutions.
• (10) A system view for the rebundling of tasks (split of
functions).

14. Performance-based financing
• A health care provider performance is not obtained
through ex ante command & ex post control or
through exhortation, but through the ex ante
establishment of a link between the delivered
performance / a behaviour and the attributed
economic resources.
• Higher performance leads to more resources (and
higher income for the manager/health staff).
• Performance has to be defined.