Pay for performance at a crossroads:Lessons from taking a global perspective

Purpose: The use of pay for performance (P4P) as an instrument to incentivise quality improvements in health care is at a crossroads in high-income countries but has remained a commonly used tool in low- and middle-income countries. The authors aimed to take stock of the evidence on effectiveness and design from across income settings to reveal insights for the future design of performance payment across income contexts. Design/methodology/approach: The authors identified Cochrane literature reviews of the use of P4P in health care in any income setting, tracked the development in the quantity and quality of evidence over time, and compared the incentive design features used across high-income countries compared to low- and middle-income countries. Findings: The quantity and quality of the evidence base have grown over time but can still be improved. Scheme design varies across income settings, and although some design choices may reflect differences in context, the authors find that incentive designers in both income settings can learn from practices used in the other setting. Originality/value: The research and literature on P4P in high-, low- and middle-income countries largely operate in silos. By taking stock of the evidence on P4P from across income settings, the authors are able to draw out key insights between these settings, which remain underexplored in the literature

Foreign Exchange Options and the Economics of Exchange Rates

Thesis (Ph.D.)--University of Washington, 2015-12Chapter 1: Historically, the currency derivative pricing literature and the macroeconomics literature on FX determination have progressed separately. In this Chapter I argue the joint study of these two strands of literature and give an overview of FX option pricing concepts and terminology crucial for this interdisciplinary study. I also explain the three sources of information about market expectations and perception of risk that can be extracted from FX option prices and review empirical methods for extracting option-implied densities of future exchange rates. As an illustration, I conclude the Chapter by investigating time series dynamics of option-implied measures of FX risk vis-a-vis market events and US government policy actions during the period January 2007 to December 2008. Chapter 2: This Chapter proposes using foreign exchange (FX) options with different strike prices and maturities to capture both FX expectations and risks. We show that exchange rate movements, which are notoriously difficult to model empirically, are well-explained by the term structures of forward premia and options-based measures of FX expectations and risk. Although this finding is to be expected, expectations and risk have been largely ignored in empirical exchange rate modeling. Using daily options data for six major currency pairs, we first show that the cross section options-implied standard deviation, skewness and kurtosis consistently explain not only the conditional mean but also the entire conditional distribution of subsequent currency excess returns for horizons ranging from one week to twelve months. This robust empirical pattern is consistent with a representative expected utility maximizing investor who, in addition to caring about the mean and variance, also cares about the skewness and kurtosis of the return distribution. Our results highlight the importance of expectations and risk in explaining exchange rate dynamics and suggest that the perennial problems faced by the empirical exchange rate literature are most likely due to overly restrictive auxiliary assumptions inherent in prevailing testing methods. Chapter 3: Standard ordinary least squares (OLS)-based tests of the uncovered interest parity (UIP) condition often make strong auxiliary assumptions beyond the joint hypotheses of rational expectations and risk-neutrality. This paper proposes using prices of foreign exchange (FX) option with different strike prices to test the time-varying risk premia explanation of the UIP puzzle. The options-based testing framework rests on the theoretical result that the forward exchange rate is the theoretical first moment of the option-implied distribution of future spot exchange rate. The framework allows us to test a more general version of FX market efficiency, which is the hypothesis that the option-implied risk-neutral distribution is an unbiased predictor of the future realized distribution of future spot rate. For five currency pairs, I do not reject the null hypothesis of UIP using the options-based approach

Adapting results-based financing to respond to endogenous and exogenous moderators in Zimbabwe

Abstract Purpose This study examines key adaptations that occurred in the Zimbabwean Results-Based Financing (RBF) programme between 2010 and 2017, locating the endogenous and exogenous factors that required adaptive response and the processes from which changes were made. Design/methodology/approach The study is based on a desk review and thematic analysis of 64 policy and academic literatures supplemented with 28 multi-stakeholder interviews. Findings The programme experienced substantive adaption between 2010 and 2017, demonstrating a significant level of responsiveness towards increasing efficiency as well as to respond to unforeseen factors that undermined RBF mechanisms. The programme was adaptive due to its phased design, which allowed revision competencies and responsive adaptation, which provide useful insights for other low-and-middle income countries (LMICs) settings where graduated scale-up might better meet contextualised needs. However, exogenous factors were often not systematically examined or reported in RBF evaluations, demonstrating that adaptation could have been better anticipated, planned, reported and communicated, especially if RBF is to be a more effective health system reform tool. Originality/value RBF is an increasingly popular health system reform tool in LMICs. However, there are questions about how exogenous factors affect RBF performance and acknowledgement that unforeseen endogenous programme design and implementation factors also greatly affect the performance of RBF. As a result, a better understanding of how RBF operates and adapts to programme level (endogenous) and exogenous (external) factors in LMICs is necessary

Who is paid in pay-for-performance? Inequalities in the distribution of financial bonuses amongst health centres in Zimbabwe

Although pay-for-performance (P4P) schemes have been implemented across low- and middle-income countries (LMICs), little is known about their distributional consequences. A key concern is that financial bonuses are primarily captured by providers who are already better able to perform (for example, those in wealthier areas), P4P could exacerbate existing inequalities within the health system. We examine inequalities in the distribution of pay-outs in Zimbabwe’s national P4P scheme (2014–2016) using quantitative data on bonus payments and facility characteristics and findings from a thematic policy review and 28 semi-structured interviews with stakeholders at all system levels. We found that in Zimbabwe, facilities with better baseline access to guidelines, more staff, higher consultation volumes and wealthier and less remote target populations earned significantly higher P4P bonuses throughout the programme. For instance, facilities that were 1 SD above the mean in terms of access to guidelines, earned 90 USD more per quarter than those that were 1 SD below the mean. Differences in bonus pay-outs for facilities that were 1 SD above and below the mean in terms of the number of staff and consultation volumes are even more pronounced at 348 USD and 445 USD per quarter. Similarly, facilities with villages in the poorest wealth quintile in their vicinity earned less than all others—and 752 USD less per quarter than those serving villages in the richest quintile. Qualitative data confirm these findings. Respondents identified facility baseline structural quality, leadership, catchment population size and remoteness as affecting performance in the scheme. Unequal distribution of P4P pay-outs was identified as having negative consequences on staff retention, absenteeism and motivation. Based on our findings and previous work, we provide some guidance to policymakers on how to design more equitable P4P schemes

Pay for performance at a crossroads: Lessons from taking a global perspective

Purpose: The use of pay for performance (P4P) as an instrument to incentivise quality improvements in health care is at a crossroads in high-income countries but has remained a commonly used tool in low- and middle-income countries. The authors aimed to take stock of the evidence on effectiveness and design from across income settings to reveal insights for the future design of performance payment across income contexts. Design/methodology/approach: The authors identified Cochrane literature reviews of the use of P4P in health care in any income setting, tracked the development in the quantity and quality of evidence over time, and compared the incentive design features used across high-income countries compared to low- and middle-income countries. Findings: The quantity and quality of the evidence base have grown over time but can still be improved. Scheme design varies across income settings, and although some design choices may reflect differences in context, the authors find that incentive designers in both income settings can learn from practices used in the other setting. Originality/value: The research and literature on P4P in high-, low- and middle-income countries largely operate in silos. By taking stock of the evidence on P4P from across income settings, the authors are able to draw out key insights between these settings, which remain underexplored in the literature.</p

Multimorbidity in Zimbabwe: Evidence and Priorities Dialogue: Workshop Report. 01 December 2023, Harare, Zimbabwe

This stakeholder dialogue brought together policymakers, researchers, technical partners, clinicians, community and patient representatives to deliberate on current evidence and identify priorities for responding to multimorbidity in Zimbabwe. The deposited document contains the final workshop report, including summaries of presentations, panel discussions, and key priority areas. The dialogue was supported by the Wellcome Trust, UK (grant no: 222177/Z/20/Z), in partnership with the Ministry of Health and Child Care Zimbabwe, The Organization for Public Health Interventions and Development, The Health Research Unit Zimbabwe, and the University of Zimbabwe