Performance-Based Incentives for Health: Conditional Cash Transfer Programs in Latin America and the Caribbean

In order to support poor families in the developing world to seek and use health care, a multi-pronged strategy is needed on both the supply and the demand side of health care. A demand-side program called Conditional Cash Transfers (CCTs) strives to reduce poverty and also increase food consumption, school attendance, and use of preventive health care. Since 1997, seven countries in Latin America have implemented and evaluated CCT programs with health and nutrition components. The core of the program is based on encouraging poor mothers to seek preventive health services and attend health education talks by providing a cash incentive for their healthy behavior (with healthy behavior representing performance). Evaluations of these programs measured outputs in the utilization of services; health knowledge, attitudes, and practice; food consumption; the supply and quality of services; as well as outcomes in vaccination rates; nutritional status; morbidity; mortality; and fertility. While CCT impact evaluations provided unambiguous evidence that financial incentives increase utilization of key services by the poor, the studies gave little attention to the impact on health-related behaviors, attitudes, and household decision-making or how these factors contribute to or limit impact on health outcomes. Recommendations include expanding the scope of future evaluations to study these effects, modeling program effects beforehand, and carefully selecting the conditions for payment so that they are not too burdensome yet not irrelevant. Continuing to focus on the extreme poor is recommended since findings show that the poorest households must reach a minimum level of food consumption before they are able to make other investments in their health and well-being.Health, Latin America, Caribbean

DEMAND FOR CHILD CARE AND FEMALE EMPLOYMENT IN COLOMBIA

Due to the increase in labor force attachment of mothers of young children in the last decade, child care policies have a renewed importance. This paper uses Colombian data to perform a characterization of the child care market, generating stylized facts to inform the debate. The main trends are: highly informal market, high participation and employment rates of mothers of young children, relatively little unmet need" for child care services and the poor facing constraints to access the market for child care, both in quantity and price. This study analyzes how Colombian families make their child care decisions, simultaneously choosing whether the mother works, whether to pay for care and what mode to use. The estimations performed suggest that there is a strong positive effect of child care choice on the mother´s working decision, and that this effect is much higher for low-income families. As children grow the availability of formal care modes becomes determinant to enable the mother´s labor force attachment."Child care

Gender Inequality in Health and Work: The Case of Latin America and the Caribbean

This technical paper reviews existing empirical evidence to track the effects of women's paid work on their own and their children's health in Latin America and the Caribbean. It begins with a brief description of the changing nature of labor markets and women's labor force participation. It then explores women's occupational health risks and mentions some initiatives that seek to respond to these risks. The next part of the report looks at the existing evidence for the positive effects of paid work on women's health and child health. The paper ends with policy recommendations.Women, Diseases, Health Policy, Workforce & Employment, occupational health and safety, women in the work force, women employees

Innovative Financing in Early Recovery: The Liberia Health Sector Pool Fund - Working Paper 288

In post-conflict Liberia, the National Health Plan set out a process for transitioning from emergency to sustainability under government leadership. The Liberia Health Sector Pool Fund, which consists of DfID, Irish Aid, UNICEF, and UNHCR, was established to fund this plan and mitigate this transition by increasing institutional capacity, reducing the transaction costs associated with managing multiple donor projects, and fostering the leadership of the Liberian Health Ministry by allocating funds to national priorities. In this paper, we discuss the design of the health pool fund mechanism, assess its functioning, compare the pooled fund to other aid mechanisms used in Liberia, and look into the enabling conditions, opportunities, and challenges of the pool fundLiberia, national health plan, aid effectivenes

An Index of the Quality of Official Development Assistance in Health - Working Paper 287

Health is one of the largest and most complex aid sectors: 16 percent of all aid went to the health sector in 2009. While many stress the importance of aid effectiveness, there are limited quantitative analyses of the quality of health aid. In this paper, we apply Birdsall and Kharas’s Quality of Official Development Assistance (QuODA) methodology to rank donors across 23 indicators of aid effectiveness in health. We present our results, track progress from 2008 to 2009, compare health to overall aid, discuss our limitations, and call for more transparent and relevant aid data in the sector level as well as the need to focus on impact and resultsofficial development assistance, health

Performance-based fi nancing at the Global Fund to Fight AIDS, Tuberculosis and Malaria: an analysis of grant ratings and funding, 2003–12

Background Performance-based fi nancing can be used by global health funding agencies to improve programme performance and thus value for money. The Global Fund to Fight AIDS, Tuberculosis and Malaria was one of the fi rst global-health funders to deploy a performance-based fi nancing system. However, its complex, multistep system for calculating and paying on grant ratings has several components that are subjective and discretionary. We aimed to test the association between grant ratings and disbursements, an indication of the extent to which incentives for performance are transmitted to grant recipients. Methods We obtained publicly available data for 508 Global Fund grants from 2003 to 2012 with performance ratings and corresponding disbursements, merged with other datasets that contained data for relevant country characteristics. We used regression analysis to identify predictors of grant disbursements in phase 2 (typically the latter 3 of 5 years of a grant), using two dependent variables: whether a grant had any phase-2 disbursements, and the phase-2 disbursement amount. In a separate analysis, we also investigated the predictors of grant performance ratings. Findings Grant performance rating in phase 1 was positively associated with having any disbursements in phase 2, but no association was seen between phase-1 ratings and phase-2 disbursement amounts. Further more, performance ratings are not replicable by external observers, both because subjective and discretionary decisions are made in the generation of performance measures and because the underlying data are not available. Interpretation The Global Fund’s present performance-based funding system does not adequately convey incentives for performance to recipients, and the organisation should redesign this system to explicitly link a portion of the funds to a simple performance measure in health coverage or outcomes, measured independently and robustly

We need a NICE for global development spending

With aid budgets shrinking in richer countries and more money for healthcare becoming available from domestic sources in poorer ones, the rhetoric of value for money or improved efficiency of aid spending is increasing. Taking healthcare as one example, we discuss the need for and potential benefits of (and obstacles to) the establishment of a national institute for aid effectiveness. In the case of the UK, such an institute would help improve development spending decisions made by DFID, the country's aid agency, as well as by the various multilaterals, such as the Global Fund, through which British aid monies is channelled. It could and should also help countries becoming increasingly independent from aid build their own capacity to make sure their own resources go further in terms of health outcomes and more equitable distribution. Such an undertaking will not be easy given deep suspicion amongst development experts towards economists and arguments for improving efficiency. We argue that it is exactly because needs matter that those who make spending decisions must consider the needs not being met when a priority requires that finite resources are diverted elsewhere. These chosen unmet needs are the true costs; they are lost health. They must be considered, and should be minimised and must therefore be measured. Such exposition of the trade-offs of competing investment options can help inform an array of old and newer development tools, from strategic purchasing and pricing negotiations for healthcare products to performance based contracts and innovative financing tools for programmatic interventions

Medication decision-making for patients with renal insufficiency in inpatient and outpatient care at a US Veterans Affairs Medical Centre: a qualitative, cognitive task analysis.

BackgroundMany studies identify factors that contribute to renal prescribing errors, but few examine how healthcare professionals (HCPs) detect and recover from an error or potential patient safety concern. Knowledge of this information could inform advanced error detection systems and decision support tools that help prevent prescribing errors.ObjectiveTo examine the cognitive strategies that HCPs used to recognise and manage medication-related problems for patients with renal insufficiency.DesignHCPs submitted documentation about medication-related incidents. We then conducted cognitive task analysis interviews. Qualitative data were analysed inductively.SettingInpatient and outpatient facilities at a major US Veterans Affairs Medical Centre.ParticipantsPhysicians, nurses and pharmacists who took action to prevent or resolve a renal-drug problem in patients with renal insufficiency.OutcomesEmergent themes from interviews, as related to recognition of renal-drug problems and decision-making processes.ResultsWe interviewed 20 HCPs. Results yielded a descriptive model of the decision-making process, comprised of three main stages: detect, gather information and act. These stages often followed a cyclical path due largely to the gradual decline of patients' renal function. Most HCPs relied on being vigilant to detect patients' renal-drug problems rather than relying on systems to detect unanticipated cues. At each stage, HCPs relied on different cognitive cues depending on medication type: for renally eliminated medications, HCPs focused on gathering renal dosing guidelines, while for nephrotoxic medications, HCPs investigated the need for particular medication therapy, and if warranted, safer alternatives.ConclusionsOur model is useful for trainees so they can gain familiarity with managing renal-drug problems. Based on findings, improvements are warranted for three aspects of healthcare systems: (1) supporting the cyclical nature of renal-drug problem management via longitudinal tracking mechanisms, (2) providing tools to alleviate HCPs' heavy reliance on vigilance and (3) supporting HCPs' different decision-making needs for renally eliminated versus nephrotoxic medications

Health Technology Assessment: global advocacy and local realities: comment on ‘Priority Setting for Universal Health Coverage: We Need Evidence-Informed Deliberative Processes, Not Just More Evidence on Cost-Effectiveness

Cost-effectiveness analysis (CEA) can help countries attain and sustain universal health coverage (UHC), as long as it is context-specific and considered within deliberative processes at the country level. Institutionalising robust deliberative processes requires significant time and resources, however, and countries often begin by demanding evidence (including local CEA evidence as well as evidence about local values), whilst striving to strengthen the governance structures and technical capacities with which to generate, consider and act on such evidence. In low- and middle-income countries (LMICs), such capacities could be developed initially around a small technical unit in the health ministry or health insurer. The role of networks, development partners, and global norm setting organisations is crucial in supporting the necessary capacities