prioritizing performance problems and choosing recipients amie batson senior health specialist the...
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Prioritizing Performance Problems and Choosing
Recipients
Amie Batson
Senior Health Specialist
The World Bank
October 2008
1. What are the levels of mortality in your country?
Nationally In various regions In rural vs urban areas Among the poor In specific groups: ethnic minorities
Most mortality causes still avoidable with low cost interventions
Cause-specific proportional mortality in the Africa region
21%
17%
4%
21%
6%2%
7%
17%
Neonatal
HIV/AIDS
Diarrhoealdiseases
Measles
Malaria
Respiratoryinfections
Injuries
Others
3. What are the key high impact interventions which can reduce mortality ?
• Household and Community Level interventions• Population-oriented interventions• Individual Clinical interventions
Household and community level interventions
Insecticide Treated Mosquito Nets
Safe water systems Use of sanitary latrines Hand washing by mother Indoor Residual Spraying
(IRS) Clean delivery and cord
care Early breastfeeding and
temperature management Universal extra
community-based care of LBW infants
Breastfeeding Complementary feeding Therapeutic Feeding Oral Rehydration Therapy Zinc for diarrhea
management Vitamin A - Treatment for
measles Chloroquine for malaria
(P.vivax) Artemisinin-based
Combination Therapy Antibiotics for U5
pneumonia Community based
management of neonatal sepsis
Population oriented interventions Family planning HPV vaccination Tetanus toxoid Preconceptual folate
supplementation Deworming in pregnancy Detection and treatment of
asymptomatic bacteriuria Treatment of syphilis in
pregnancy Prevention and treatment of iron
deficiency anemia in pregnancy Intermittent preventive treatment
(IPTp) for malaria in pregnancy Balanced protein energy
supplements for pregnant women Supplementation in pregnancy
with multi-micronutrients
PMTCT VCT Cotrimoxazole prophylaxis for HIV+ Childhood Immunization
Measles BCG OPV DPT Hib Hepatitis B Yellow fever Meningococcal A/C Pneumococcal Rotavirus
Neonatal Vitamin A supplementation Vitamin A - supplementation Zinc preventive
Individual clinical interventions
Skilled attended delivery Basic emergency obstetric care (B-EOC) Resuscitation of asphyctic newborns at
birth Antenatal steroids for preterm labor Antibiotics for Preterm/Prelabour Rupture
of Membrane (P/PROM) Detection and management of
(pre)ecclampsia (Mg Sulphate) Management of neonatal infections Antibiotics for U5 pneumonia Antibiotics for diarrhea and enteric fevers
Vitamin A - Treatment for measles
Zinc for diarrhea management
Clinical management of neonatal jaundice
Management of severely sick children (referral IMCI)
Chloroquine for malaria (P.vivax)
Artemisinin-based Combination Therapy
Management of complicated malaria (2nd line drug)
Individual clinical interventions
Management of opportunistic infections
Male circumcision Second-line ART Adult second-line ART Comprehensive emergency
obstetric care (C-EOC) Other emergency acute
care
Detection and management of STI
Management of opportunistic infections
First line ART Detection and treatment of TB
with first line drugs (category 1 and 3)
Re-treatment of TB patients with first line drugs (category 2)
MDR treatement with second line drugs
Saving 1.3 million lives per year for $ 400 per life saved: jumpstarting community care & outreach
Expected Impact on Neonatal, Under Five and Maternal Mortality and Additional Economic Cost
$ 0.66
$ 0.00
$ 0.43
$ 0.22
0%
5%
10%
15%
20%
25%
Family/community Outreach/schedulable Clinical Total Services
Delivery modes
Mo
rtali
ty r
ed
ucti
on
$0.0
$0.5
$1.0
Neonatal Mortality Under Five Mortality
Maternal Mortality Incremental Economic Costs per capita/year
Scenario I : Africa generic
Saving 2.5 million lives per year for $ 800 per life saved: Full Minimum Package at scale:
Expected Impact on Neonatal, Under Five and Maternal Mortality and Additional Economic Cost
$ 2.48
$ 0.72
$ 1.09
$ 0.67
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Family/community Outreach/schedulable Clinical Total Services
Delivery modes
Mo
rtali
ty r
ed
ucti
on
$0.0
$0.5
$1.0
$1.5
$2.0
$2.5
$3.0
Neonatal Mortality Under Five Mortality
Maternal Mortality Incremental Economic Costs per capita/year
Phase I : Africa generic
Saving 5.5 million lives per year for $ 1,500 per life saved: maximum package at scale.
Expected Impact on Neonatal, Under Five and Maternal Mortality and Additional Economic Cost
$ 9.26
$ 1.31
$ 4.11 $ 3.84
0%5%
10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%
Family/community Outreach/schedulable Clinical Total Services
Delivery modes
Mo
rtali
ty r
ed
ucti
on
$0
$1
$2
$3
$4
$5
$6
$7
$8
$9
$10
Neonatal MortalityUnder Five MortalityMaternal MortalityIncremental Economical Costs per capita/year
Phase III : Africa generic
5. So why is it not happening ? Supply issues ?
Do people have physical access to services ? Infrastructure? Equipment?
Are human resources available? Are commodities and pharmaceuticals available? Is quality of care a major problem
Demand issues ? Is demand for services low? Is continuity of services or compliance low? Is low demand due to financial barriers, social and
cultural barriers ?
Who should be the recipient of RBF? What is the reasons for low coverage? Where should the RBF
incentive be targeted?
Health worker Individual action (working harder) all that is needed. Benefits outweigh the high costs of monitoring and rewarding
performance at this level
Health facility: Work of facility team is needed System changes are needed Improve performance of different providers: public, private,
NGO
Consumer (community, family, mother): Hidden costs (transport, food) constraining demand Community needed to support families / encourage demand
How might you target recipients?
Health facilities Are all health facilities eligible? Or does scheme target public sector facilities? Private
sector? NGO? Does the scheme target facilities in specific provinces (e.g.,
poorest)
Consumer (community, family, mother) Geographic – target all living in poorest provinces or districts Means test – target poorest families in an area Target all demanding/requiring a priority service
All pregnant women to encourage institutional delivery
Example from MCH
Performance problem: Low % of women delivering in facility with trained health worker
Underlying causes: Consumer side: can’t afford transportation, mother-in-law or
community discourages it, can’t afford food or cost of drugs Provider side: poor quality service, rude to mothers, no effort to
follow up after antenatal visits . Provider paid a fixed salary regardless of performance.
Other: Drugs not available. Health workers not well trained
Potential results-based incentives Patient side: subsidies to cover transportation costs, food packages
or money when deliver at the institution Provider: Payment for increased number of women delivering in
facilities
Examples: Objectives and Recipients
Objective Recipient
Increase institutional deliveries as means for reducing MMR
Improve 6-10 indicators of performance e.g. DPT3, ANC, CPR, SBA,
Increase % of childen/mothers sleeping under LLINs last night, especially among the poor
Improve demand: Mothers, TBA
Increase supply: TBA, Service provider
Increase supply: Service providers (NGO, public, private, sub-national)
Increase use of services: community, household
Service provider (NGO, public, private) in a poorly performing district
Designing RBF questions
1. What are the levels of mortality in your country?
2. What are the causes of mortality?3. What are the key high impact interventions
which can reduce mortality?4. What could be achieved if the coverage with
high interventions increases?5. So why is it not happening ?6. Who should be the recipient of RBF?
What is the potential for RBF? Rwanda: back on track for the MDGs
Progress towards the MDGs
$8.83
$19.98
$29.35
0%
10%
20%
30%
40%
50%
60%
70%
80%
Phase I Phase II Phase III
$0
$5
$10
$15
$20
$25
$30
$35
Anaemia Reduction of Low Birth weight Estimated reduction in stunting U5MR reduction
IMR reduction NNMR reduction MMR reduction Lifetime Risk of Dying
Total fertility rate (TFR) Reduction of Malaria Mortality Reduction in AIDS mortality Reduction in TB Mortality
Quality of drinking water Use of sanitary laterin Hand washing by mother Cost per capita per year in US$
MDG 1 MDG4 MDG 7MDG 6MDG5