PAY-FOR-PERFORMANCE FOR HEALTH SERVICE PROVIDERS Effectiveness, Design, Context, and Implementation

Countries are increasingly implementing pay for performance (P4P) as a way to improve health services. The evidence base is conflicting and difficult to interpret. It is necessary to more systematically explore evaluations of P4P schemes in order to synthesize more useful evidence to inform the use of P4P schemes in health care. This thesis starts with a literature review, which shows that the results of evaluations of P4P schemes are heterogeneous, which may possibly be explained by differences in programme design, context, implementation, and evaluation study design. I sought to find ways to better analyse and make sense of these evaluations using two approaches. A quantitative approach was used to systematically explore the heterogeneity. I developed and tested a theoretical typology to categorise P4P schemes by their design features. This typology considers who receives the incentive, type of incentive, size of incentive, and perceived risk of not earning the incentive. I then used the typology to quantitatively explore the influence of P4P design features and evaluation designs on it effectiveness using meta-regression and multilevel logistic regression analyses. I also undertook a formative evaluation of a pilot P4P scheme in Nigeria (a case study). This used semi-structured in-depth interviews with 36 purposively sampled health workers to explore how contextual and implementation factors (e.g. delay in incentive payment) influenced the impact of the scheme. This research presents three notable and novel contributions to knowledge about P4P in healthcare. First a useful typology was developed, which can be used to help categorize, think about, structure and report P4P schemes in a standardized and theoretically informed way. Second, I show that P4P schemes with design features such as payment to groups, large incentive size (>5% of salary or usual budget), and low perceived risk of not earning the incentive are more likely to be effective compared to schemes characterized by payment to individuals, small incentives, and high perceived risk of not earning the incentive. In addition, I demonstrate that P4P evaluations without adequate controls over-estimate the effectiveness of P4P. Third, I show that contextual factors such as incentive payment delays, poor health worker understanding of the P4P scheme, and poor infrastructure affect the effectiveness of the Nigerian P4P scheme and need to be addressed in its future development

An assessment of primary health care costs and resource requirements in Kaduna and Kano, Nigeria

IntroductionThe availability of quality primary health care (PHC) services in Nigeria is limited. The PHC system faces significant challenges and the improvement and expansion of PHC services is constrained by low government spending on health, especially on PHC. Out-of-pocket (OOP) expenditures dominate health spending in Nigeria and the reliance on OOP payments leads to financial burdens on the poorest and most vulnerable populations. To address these challenges, the Nigerian government has implemented several legislative and policy reforms, including the National Health Insurance Authority (NHIA) Act enacted in 2022 to make health insurance mandatory for all Nigerian citizens and residents. Our study aimed to determine the costs of providing PHC services at public health facilities in Kaduna and Kano, Nigeria. We compared the actual PHC service delivery costs to the normative costs of delivering the Minimum Service Package (MSP) in the two states.MethodsWe collected primary data from 50 health facilities (25 per state), including PHC facilities—health posts, health clinics, health centers—and general hospitals. Data on facility-level recurrent costs were collected retrospectively for 2019 to estimate economic costs from the provider’s perspective. Statewide actual costs were estimated by extrapolating the PHC cost estimates at sampled health facilities, while normative costs were derived using standard treatment protocols (STPs) and the populations requiring PHC services in each state.ResultsWe found that average actual PHC costs per capita at PHC facilities—where most PHC services should be provided according to government guidelines—ranged from US$18.9 to US$ 28 in Kaduna and US$15.9 to US$ 20.4 in Kano, depending on the estimation methods used. When also considering the costs of PHC services provided at general hospitals—where approximately a third of PHC services are delivered in both states—the actual per capita costs of PHC services ranged from US$20 to US$ 30.6 in Kaduna and US$17.8 to US$ 22 in Kano. All estimates of actual PHC costs per capita were markedly lower than the normative per capita costs of delivering quality PHC services to all those who need them, projected at US$44.9 in Kaduna and US$ 49.5 in Kano.DiscussionBridging this resource gap would require significant increases in expenditures on PHC in both states. These results can provide useful information for ongoing discussions on the implementation of the NHIA Act including the refinement of provider payment strategies to ensure that PHC providers are remunerated fairly and that they are incentivized to provide quality PHC services

Engaging stakeholders to identify gaps and develop strategies to inform evidence use for health policymaking in Nigeria

Introduction: recent efforts to bridge the evidence-policy gap in low-and middle-income countries have seen growing interest from key audiences such as government, civil society, international organizations, private sector players, academia, and media. One of such engagement was a two-day virtual participant-driven conference (the convening) in Nigeria. The aim of the convening was to develop strategies for improving evidence use in health policy. The convening witnessed a participant blend of health policymakers, researchers, political policymakers, philanthropists, global health practitioners, program officers, students, and the media. Methods: in this study, we analyzed conversations at the convening with the aim to disseminate findings to key stakeholders in Nigeria. The recordings from the convening were transcribed and analyzed inductively to identify emerging themes, which were interpreted, and inferences are drawn. Results: a total of 630 people attended the convening. Participants joined from 13 countries. Participants identified poor collaboration between researchers and policymakers, poor community involvement in research and policy processes, poor funding for research, and inequalities as key factors inhibiting the use of evidence for policymaking in Nigeria. Strategies proposed to address these challenges include the use of participatory and embedded research methods, leveraging existing systems and networks, advocating for improved funding and ownership for research, and the use of context-sensitive knowledge translation strategies. Conclusion: overall, better interaction among the various stakeholders will improve the evidence generation, translation, and use in Nigeria. A road map for the dissemination of findings from this conference has been developed for implementation across the strata of the health system

Engaging stakeholders to identify gaps and develop strategies to inform evidence use for health policymaking in Nigeria.

INTRODUCTION: recent efforts to bridge the evidence-policy gap in low-and middle-income countries have seen growing interest from key audiences such as government, civil society, international organizations, private sector players, academia, and media. One of such engagement was a two-day virtual participant-driven conference (the convening) in Nigeria. The aim of the convening was to develop strategies for improving evidence use in health policy. The convening witnessed a participant blend of health policymakers, researchers, political policymakers, philanthropists, global health practitioners, program officers, students, and the media. METHODS: in this study, we analyzed conversations at the convening with the aim to disseminate findings to key stakeholders in Nigeria. The recordings from the convening were transcribed and analyzed inductively to identify emerging themes, which were interpreted, and inferences are drawn. RESULTS: a total of 630 people attended the convening. Participants joined from 13 countries. Participants identified poor collaboration between researchers and policymakers, poor community involvement in research and policy processes, poor funding for research, and inequalities as key factors inhibiting the use of evidence for policymaking in Nigeria. Strategies proposed to address these challenges include the use of participatory and embedded research methods, leveraging existing systems and networks, advocating for improved funding and ownership for research, and the use of context-sensitive knowledge translation strategies. CONCLUSION: overall, better interaction among the various stakeholders will improve the evidence generation, translation, and use in Nigeria. A road map for the dissemination of findings from this conference has been developed for implementation across the strata of the health system

A Reporting Framework for Describing and a Typology for Categorizing and Analyzing the Designs of Health Care Pay for Performance Schemes

Table S1. Search strategy output for Cochrane database. This table details the search strategy employed to identify relevant studies and reviews used in the manuscript. This includes the database searched, years covered, and number of citations. Table S2. Summary of identified reviews. This table outlines the relevant reviews and P4P evaluation studies identified from our search strategy, which informed our reporting framework and typology. Table S3. Search strategy output for economic theories to inform the P4P typology. This table details the search strategy employed to identify relevant economic theories that were used to construct the P4P typology. This includes the database searched, years covered, and number of citations. Table S4. Application of the typology on selected identified P4P schemes. This table outlines the results of applying the P4P typology to categorized identified P4P schemes. Table S5. P4P studies used in testing the inter-rater reliability of the P4P typology. This table list out the P4P studies that were selected for the raters to apply the P4P typology. Table S6. Rater population. This table describes the rater population i.e. qualifications, research experience, and experience with P4P in healthcare. Table S7. Sources of disagreement between raters. This table highlights the items on the P4P typology that were sources of disagreement between he raters. Table S8. An example of source of disagreement between raters (risk). This table details text extracts from the sample P4P study and describes the reason for disagreement between raters testing the P4P typology. (DOCX 127 kb

The Effectiveness of Payment for Performance in health care : a meta-analysis and exploration of variation in outcomes

Background. Pay for performance (P4P) incentive schemes are increasingly used world-wide to improve health system performance but results of evaluations vary considerably. A systematic analysis of this variation in the effects of P4P schemes is needed. Methods. Evaluations of P4P schemes from any country were identified by searching for and updating systematic reviews of P4P schemes in health care in four bibliographic databases. Outcomes using different measures of effect were converted into standardised effect sizes and each study was categorised as to whether or not it found a positive effect. Subgroup analysis, meta-regression and multilevel logistic regression were used to investigate factors explaining heterogeneity. Random-effects models were used because they take into account heterogeneity likely to be due to differences between studies rather than just chance. Sensitivity analysis was used to test the effect of different assumptions. Findings. 96 primary studies were identified; 37 were included in the meta-analysis and meta-regression and all 96 in the logistic regression. The proportion of observed variation in study results that can be explained by true heterogeneity (I2) was 99.9%. Estimates of effect of P4P schemes were lower in evaluations using randomised controlled trials (SMD=0∙08; 95% CI: 0∙01 to 0∙15) compared to no controls (0∙15; 95%CI: 0∙09 to 0∙21), and lower for those measuring outcomes (e.g. smoking cessation) (SMD=0∙0; 95%CI: -0∙01 to 0∙01) compared to process measures (e.g. giving cessation advice) (0∙18; 95%CI: 0∙06 to 0∙31).Adjusting for other design features and the evaluation method, the odds of showing a positive effect was three times higher for schemes with larger incentives (>5% of salary/usual budget) (OR = 3∙38; 95%CI: 1∙07 to 10∙64). There were non-statistically significant increases in the odds of success if the incentive is paid to individuals (as opposed to groups) (OR= 2∙0; 95%CI: 0∙62 to 6∙56) and if there is a lower perceived risk of not earning the incentive (OR= 2∙9; 95%CI: 0∙78 to 10∙83). Schemes evaluated using less rigorous designs were 24 times more likely to have positive estimates of effect than those using randomised controlled trials (OR = 24; 95%CI: 6∙3 to 92∙8). Interpretation. Estimates of the effectiveness of incentive schemes on health outcomes are probably inflated due to poorly designed evaluations and a focus on process measures rather than health outcomes. Larger incentives and reducing the perceived risk of non-payment may increase the effect of these schemes on provider behaviour

Factors influencing willingness and ability to pay for social health insurance in Nigeria.

BackgroundMany low and middle-income countries are increasingly cognisant of the need to offer financial protection to its citizens through pre-payment schemes in order to curb high out of pocket expenditure and catastrophic spending on healthcare. However, there is limited rigorous contextual evidence to make decisions regarding optimal design of such schemes. This study assesses the willingness-to-pay (WTP) for the recently introduced state contributory health insurance scheme (SHIS) in Nigeria.MethodsThe study took place in 6 local government areas in Kaduna state, North-west Nigeria. Data were collected from a household survey using a three-stage cluster sampling approach, with each household having the same probability of being selected. Interviews were conducted with 4000 individuals in 1020 households. Contingent valuation was used to elicit the willing to pay (WTP) for the household using the bidding game technique. The relationship between socioeconomic status and WTP was also examined using logistic regression models.FindingsAbout 82% of the household heads were willing to pay insurance premiums for their households, which came to an average of 513 Naira (1.68 USD) per month per person. The average amount individuals were willing to pay was lower in rural areas (611 Naira) compared to urban areas (463 Naira). These results were influenced by household size, level of education, occupation and household income. In addition, only 65% of the households had the ability to pay the average premium.ConclusionSocioeconomic factors influence individuals' WTP for contributory health insurance schemes. It is important to create awareness about the benefits of the insurance scheme, especially in rural areas, and in both the formal and informal sectors in Nigeria. WTP information can inform the amount of insurance premiums. However, it is important to consider differences between the WTP and the cost of benefits package to be offered, as the premium amount may need to be subsidized with public financing

Is Nigeria on course to achieve universal health coverage in the context of its epidemiological and financing transition? A knowledge, capacity and policy gap analysis (a qualitative study)

Objectives This study aimed to assess Nigeria’s preparedness to finance and drive the universal health coverage (UHC) agenda within the context of changing health conditions and resource needs associated with the disease, demographic and funding transitions.Nigeria is undergoing transitions in the healthcare system that include a double burden of infectious and non-communicable diseases, and transition from concessional donor assistance towards domestic financing for health. These transitions will affect Nigeria’s attainment of UHC.Design and setting We conducted a qualitative study, including semistructured interviews with relevant stakeholders at national and subnational levels in Nigeria. Data from the interviews were analysed using thematic analysis.Participants Our study involved 18 respondents from government ministries, departments, and agencies, development partners, civil society organisations and academia.Results Capacity gaps identified by respondents included limited knowledge to implement health insurance schemes at subnational levels, poor information/data management to monitor progress towards UHC and limited communication and interagency collaboration between government agencies and ministries. Furthermore, participants in our study expressed those current policies driving major health reforms like the National Health Act (basic healthcare provision fund) appear adequate to support UHC advancement in theory, but policy implementation is a key challenge due to a lack of policy awareness, low government spending on health and poor evidence generation for information to support decisions.Conclusion Our study found major gaps in knowledge and capacity for UHC advancement in the context of Nigeria’s demographic, epidemiological and financing transitions. These included poor knowledge of demographic transitions, poor capacity for health insurance implementation at subnational levels, low government spending on health, poor policy implementation and poor communication and collaboration among stakeholders. To address these challenges, collaborative efforts are needed to bridge knowledge gaps and increase policy awareness through targeted knowledge products, improved communication and interagency collaboration

Table_1_An assessment of primary health care costs and resource requirements in Kaduna and Kano, Nigeria.docx

IntroductionThe availability of quality primary health care (PHC) services in Nigeria is limited. The PHC system faces significant challenges and the improvement and expansion of PHC services is constrained by low government spending on health, especially on PHC. Out-of-pocket (OOP) expenditures dominate health spending in Nigeria and the reliance on OOP payments leads to financial burdens on the poorest and most vulnerable populations. To address these challenges, the Nigerian government has implemented several legislative and policy reforms, including the National Health Insurance Authority (NHIA) Act enacted in 2022 to make health insurance mandatory for all Nigerian citizens and residents. Our study aimed to determine the costs of providing PHC services at public health facilities in Kaduna and Kano, Nigeria. We compared the actual PHC service delivery costs to the normative costs of delivering the Minimum Service Package (MSP) in the two states.MethodsWe collected primary data from 50 health facilities (25 per state), including PHC facilities—health posts, health clinics, health centers—and general hospitals. Data on facility-level recurrent costs were collected retrospectively for 2019 to estimate economic costs from the provider’s perspective. Statewide actual costs were estimated by extrapolating the PHC cost estimates at sampled health facilities, while normative costs were derived using standard treatment protocols (STPs) and the populations requiring PHC services in each state.ResultsWe found that average actual PHC costs per capita at PHC facilities—where most PHC services should be provided according to government guidelines—ranged from US$18.9 to US$ 28 in Kaduna and US$15.9 to US$ 20.4 in Kano, depending on the estimation methods used. When also considering the costs of PHC services provided at general hospitals—where approximately a third of PHC services are delivered in both states—the actual per capita costs of PHC services ranged from US$20 to US$ 30.6 in Kaduna and US$17.8 to US$ 22 in Kano. All estimates of actual PHC costs per capita were markedly lower than the normative per capita costs of delivering quality PHC services to all those who need them, projected at US$44.9 in Kaduna and US$ 49.5 in Kano.DiscussionBridging this resource gap would require significant increases in expenditures on PHC in both states. These results can provide useful information for ongoing discussions on the implementation of the NHIA Act including the refinement of provider payment strategies to ensure that PHC providers are remunerated fairly and that they are incentivized to provide quality PHC services.</p

Achieving global mortality reduction targets and universal health coverage: The impact of COVID-19.

Wenhui Mao and coauthors discuss possible implications of the COVID-19 pandemic for health aspirations in low- and middle-income countries