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pay-For-performance

Financial incentives in health: supply- vs. demand-side. Your help is needed!

Adam Wagstaff's picture

A blogpost on financial incentives in health by one of us in September 2015 generated considerable interest. The post raised several issues, one being whether demand-side financial incentives (like maternal vouchers) are more or less effective at increasing the uptake of key maternal and child health (MCH) interventions than supply-side financial incentives (variously called pay-for-performance (P4P) or performance-based financing (PBF)).

The four of us are now hard at work investigating this question — and related ones — in a much more systematic fashion. And we'd very much welcome your help.

Financial incentives in health: the magic bullet we were hoping for?

Adam Wagstaff's picture

After years of bad news from developing countries about high rates of health worker absenteeism, and low rates of delivery of key health interventions, along came what seemed like a magic bullet: financial incentives. Rather than paying providers whether or not they show up to work, and whether or not they deliver key interventions, doesn’t it make sense to pay them—at least in part—according to what they do? And if, after doing their cost-benefit calculations, women decide not to have their baby delivered in a health facility, not to get antenatal care, and not take their child to be immunized, then doesn’t it make sense to try to change the benefit-cost ratio by paying them to do so?

We just learned a whole lot more about achieving Universal Health Coverage

Adam Wagstaff's picture

Subsidized health insurance is unlikely to lead to Universal Health Coverage (UHC); insurance coverage doesn’t always improve financial protection and when it does, doesn’t necessarily eliminate financial protection concerns; and tackling provider incentives may be just as – if not more – important in the UHC agenda as demand-side initiatives. These are the three big and somewhat counterintuitive conclusions of the Health Equity and Financial Protection in Asia (HEFPA) research project that I jointly coordinated with Eddy van Doorslaer and Owen O’Donnell.

As we all now know, UHC is all about ensuring that everyone – irrespective of their ability to pay – can access the health services they need without suffering undue financial hardship in the process. The HEFPA project set out to explore the effectiveness of a number of UHC strategies in a region of the world that has seen a lot of UHC initiatives: East Asia. The project pooled the skills of researchers from six Asian countries (Cambodia, China, Indonesia, the Philippines, Thailand and Vietnam), several European universities and the World Bank.

Do financial incentives undermine the motivation of public sector workers? Maybe, but where is the evidence from the field?

Jed Friedman's picture
These past weeks I’ve visited several southern African nations to assist on-going evaluations of health sector pay-for-performance reforms. It’s been a whirlwind of government meetings, field trips, and periods of data crunching. We’ve made good progress and also discovered roadblocks – in other words business as usual in this line of work. One qualitative data point has stayed with me throughout these weeks, the paraphrased words of one clinic worker: “I like this new program because it makes me feel that the people in charge of the system care about us.”

Sifting through data to detect deliberate misreporting in pay-for-performance schemes

Jed Friedman's picture

As empiricists, we spend a lot of time worrying about the accuracy of economic and socio-behavioral measurement. We want our data to reflect the targeted underlying truth. Unfortunately misreporting, either accidental or deliberate, from study subjects is a constant risk. The deliberate kind of misreporting is much more difficult to deal with because it is driven by complicated and unobserved respondent intentions – either to hide sensitive information or to try to please the perceived intentions of the interviewer. Respondents who misreport information for their own benefit are said to be “gaming”, and the challenge of gaming extends beyond research activities to development programs that depend on the accuracy of self-reported information for success.

Reporting from the International Health Economics Association 8th World Congress

Jed Friedman's picture

I’m currently attending this large conference in lovely Toronto and trying to pack-in as many sessions as possible. A handful of papers have stood out to me – two evaluations of on-going pay-for-performance schemes in health and two methodological papers related to the economics of obesity.

What makes health workers get up in the morning? Paying-for-performance and worker motivation

Jed Friedman's picture

Economists have long noted that the price mechanism can be effective at modifying human behavior. Psychologists classify this aspect of behavior motivation as extrinsic motivation, meaning that the behavior is induced by external pressure. If I increase my hours worked due to an overtime premium then I can be said to exhibit extrinsic motivation - I am responding to the price schedule offered me. In contrast to extrinsic motivation, psychologists posit intrinsic motivation as arising from within the individual.

Verifying the performance in pay-for-performance: What little we know and how we can learn

Jed Friedman's picture

Numerous recent discussions on the future of development financing focus on the delivery of results and how to mainstream accounting for results in aid flows (see here for one review paper by Nemat Shafik). This “results based approach” to aid is gathering steam in many contexts.