Performance-Based Financing: Report on Feasibility and Implementation Options Final September 2007

This study examines the feasibility of introducing a performance-related bonus scheme in the health sector. After describing the Tanzania health context, we define “Performance-Based Financing”, examine its rationale and review the evidence on its effectiveness. The following sections systematically assess the potential for applying the scheme in Tanzania. On the basis of risks and concerns identified, detailed design options and recommendations are set out. The report concludes with a (preliminary) indication of the costs of such a scheme and recommends a way forward for implementation. We prefer the name “Payment for Performance” or “P4P”. This is because what is envisaged is a bonus payment that is earned by meeting performance targets1. The dominant financing for health care delivery would remain grant-based as at present. There is a strong case for introducing P4P. Its main purpose will be to motivate front-line health workers to improve service delivery performance. In recent years, funding for council health services has increased dramatically, without a commensurate increase in health service output. The need to tighten focus on results is widely acknowledged. So too is the need to hold health providers more accountable for performance at all levels, form the local to the national. P4P is expected to encourage CHMTs and health facilities to “manage by results”; to identify and address local constraints, and to find innovative ways to raise productivity and reach under-served groups. As well as leveraging more effective use of all resources, P4P will provide a powerful incentive at all levels to make sure that HMIS information is complete, accurate and timely. It is expected to enhance accountability between health facilities and their managers / governing committees as well as between the Council Health Department and the Local Government Authority. Better performance-monitoring will enable the national level to track aggregate progress against goals and will assist in identifying under-performers requiring remedial action. We recommend a P4P scheme that provides a monetary team bonus, dependent on a whole facility reaching facility-specific service delivery targets. The bonus would be paid quarterly and shared equally among health staff. It should target all government health facilities at the council level, and should also reward the CHMT for “whole council” performance. All participating facilities/councils are therefore rewarded for improvement rather than absolute levels of performance. Performance indicators should not number more than 10, should represent a “balanced score card” of basic health service delivery, should present no risk of “perverse incentive” and should be readily measurable. The same set of indicators should be used by all. CHMTs would assist facilities in setting targets and monitoring performance. RHMTs would play a similar role with respect to CHMTs. The Council Health Administration would provide a “check and balance” to avoid target manipulation and verify bonus payments due. The major constraint on feasibility is the poor state of health information. Our study confirmed the findings of previous ones, observing substantial omission and error in reports from facilities to CHMTs. We endorse the conclusion of previous reviewers that the main problem lies not with HMIS design, but with its functioning. We advocate a particular focus on empowering and enabling the use of information for management by facilities and CHMTs. We anticipate that P4P, combined with a major effort in HMIS capacity building – at the facility and council level – will deliver dramatic improvements in data quality and completeness. We recommend that the first wave of participating councils are selected on the basis that they can first demonstrate robust and accurate data. We anticipate that P4P for facilities will not deliver the desired benefits unless they have a greater degree of control to solve their own problems. We therefore propose - as a prior and essential condition – the introduction of petty cash imprests for all health facilities. We believe that such a measure would bring major benefits even to facilities that have not yet started P4P. It should also empower Health Facility Committees to play a more meaningful role in health service governance at the local level. We recommend to Government that P4P bonuses, as described here, are implemented across Mainland Tanzania on a phased basis. The main constraint on the pace of roll-out is the time required to bring information systems up to standard. Councils that are not yet ready to institute P4P should get an equivalent amount of money – to be used as general revenue to finance their comprehensive council health plans. We also recommend that up-to-date reporting on performance against service delivery indicators is made a mandatory requirement for all councils and is also agreed as a standard requirement for the Joint Annual Health Sector Review. P4P can also be applied on the “demand-side” – for example to encourage women to present in case of obstetric emergencies. There is a strong empirical evidence base from other countries to demonstrate that such incentives can work. We recommend a separate policy decision on whether or not to introduce demand-side incentives. In our view, they are sufficiently promising to be tried out on an experimental basis. When taken to national scale (all councils, excepting higher level hospitals), the scheme would require annual budgetary provision of about 6 billion shillings for bonus payments. This is equivalent to 1% of the national health budget, or about 3% of budgetary resources for health at the council level. We anticipate that design and implementation costs would amount to about 5 billion shillings over 5 years – the majority of this being devoted to HMIS strengthening at the facility level across the whole country

Weed Search and Control: Theory and Application

The detectability of invasive organisms influences the costs and benefits of alternative control strategies, and the feasibility of eradicating an infestation. Search theory offers a mathematically rigorous framework for defining and measuring detectability, taking account of searcher ability, biological factors and the search environment. To demonstrate the application of search theory to invasive species control, invasive species detectability is incorporated into a population simulation model. The model is applied to a base set of parameter values that represent reasonable values for a hypothetical weed. The analysis shows the effects of detectability and search time on the duration of an eradication program. Furthermore, for a given level of detectability and search time, the analysis shows that the variables with the greatest influence on the duration of the eradication effort are search speed, kill efficiency and seed longevity. A series of Monte Carlo simulations are performed on a set of five scenarios, involving different combinations of plant longevity, seed longevity and plant fecundity. Results of these simulations are presented as probability distributions and allow us to calculate how the probability of eradication will be affected by search strategy.search and control, search theory, weed control, stage matrix, impedance factors, population dynamics, stochastic model, Farm Management,

Challenges and Choices: Modelling New Zealand’s Long-term Fiscal Position

This working paper provides further detail on the modelling behind Challenges and Choices – New Zealand’s Long-Term Fiscal Statement, published on 29 October 2009. Building on the first Statement of 2006, we construct two main fiscal scenarios over a 40- year horizon. The historic trends scenario allows historic and current spending and revenue settings to interact with changing demography. The sustainable debt scenario applies a fiscal constraint on non-benefit spending so that Crown net debt follows the Government’s medium-term fiscal targets. The modelling innovations introduced this time do not alter the basic structure and principles of the Long-term Fiscal Model, but instead provide insights into government spending: public sector productivity growth and the growth of the basket of services each person receives. These innovations enable us to illustrate the effects of tradeoffs between broad spending categories in a constrained fiscal environment. In the 2009 Statement, these policy changes are combined into three possible scenarios for obtaining a sustainable fiscal position. The paper also illustrates the sensitivity of the fiscal position to small changes in the demographic, macroeconomic and fiscal modelling assumptions.Population, projections, social expenditure, fiscal costs, New Zealand

My iPhone Made Me Do It!

Companies around the world invest an increasing amount of money trying to protect themselves from cybercrime and unauthorized access of valuable data. The nature of these covert threats makes it seemingly impossible to quantify the risk of getting attacked. While it is possible to estimate the tangible costs of a security breach it is much harder to asses what a company stands to lose in terms of intangible costs. This thesis uses the Event Study methodology to determine the intangible losses of listed American companies who suffered data breaches. On average, the companies in the dataset loses 0.21% of their market cap after a security breach which, although not being statistically significant, translates to $267 million. Despite looking at several parameters to find significant predictors, only one turned out to be statistically significant, namely the number of records breached. These weak correlation is a result in itself; because of the low impact of a breach perhaps the companies lack proper incentives to protect their users' data.Det ständigt växande cyberhotet gör att allt fler företag väljer att göra stora investeringar i datasäkerhet. Den dolda hotbilden gör det i stort sett omöjligt att kvantifiera sannolikheten för att råka ut för en attack. Även om det går att avgöra och förutspå de direkta kostnaderna kring ett dataintrång så är det nästintill omöjligt att avgöra de indirekta kostnaderna kring ett dataintrång. Detta arbete använder eventstudie-metodologin för att uppskatta de indirekta kostnaderna hos börsnoterade amerikanska företag efter att de haft ett dataintrång. Företagen i den undersökta datamängden förlorar i genomsnitt 0.21$267 miljoner. Arbetet undersöker ett antal parametrar för att hitta signifikanta prediktorer men endast en av de prediktorer vi undersökte var statistiskt signifikant, nämligen antalet läckta uppgifter. Dessa svaga samband är i sig intressanta; den till synes svaga inverkan av dataintrång på företagens börsvärde antyder att de kanske inte har så stora finansiella incitament att skydda sina kunders data