Signs of P4P enhanced functioning of accountability mechanisms in the health system: experience

from Pwani Pay for Performance (P4P) pilot

Iddy Mayumana

Introduction

RBF seen as a policy option to improve providers’ motivation, accountability and performance Little is known about its effects on

accountability

This study examines the effects of the P4P pilot on accountability mechanisms

MethodsProcess monitoring (2011-2015) • In-depth interviews (86) • Group interviews (12) • Focus group discussions (18) • Review of relevant documents • Observations during performance

feedback meetings conducted

Methods

Impact evaluation (2012 and after 2013) • 150 health facilities • Household survey of 3000 women

delivered in last 12 months prior to the interview was conducted

Conceptual framework: Cleary et al (2013)

Internal accountability:    aims at regulating answerability on the

supply side by focusing on accountability within and/or

between different levels of the health system, such as management and supervision, as well as budgeting and prioritisation   

External accountability : aims at regulating answerability between

providers and service users

Internal accountability: Management and Supervision

P4P had a positive and significant effect on: • Timeliness of supervision • The provision of positive and negative feedback during

supervision. Close supervision improved health data reporting for

P4P targeted services Supervision visits aimed at problem solving (drugs, HR

issues) – improved relations No significant effect on the number of administrative

or managerial meetings held during the last 90 days Improved relations between district and national level

stakeholders (less bureucratic) – some staff at district level did not cooperate

Internal accountability: budgeting and prioritisation

Score cards and payment to facility accounts enhanced trust

P4P entailed a significant reduction of the interruption of service delivery due to broken equipment and in the stock out rate of drugs and medical supplies

Funds allocation at the facility level was mainly influenced by a goal to achieve P4P targets

External accountability: to users

Health workers more responsive and respectful to their clients

Increase in provider kindness reported by patients during delivery, a positive 0.38 point increase in the mean kindness score (95% CI: -0.06 to 0.80).

No significant effect of P4P on the proportion of health facilities with a governing committee

A positive and significant increase on the probability of having hold a meeting in the last 90 days

HFGC involvement was enhanced during P4P fund management (approve the budget)

Bonus spent on allowances for committee members

External accountability: to usersHealth workers reported wanting to increase

outreach activities but were hindered by lack of resources

No effect on number of outreach activities in the communities in the last 90 days (transport?)

When clustering at district level we find a significant increase of 0.52 (SE: 0.0274)  in the number of outreach visits

Conclusions P4P has shown to have the potential to

contribute to: • Improving supportive supervision; • Data reporting and verification; • Financial management at the facility level; • Build trust, relationship and teamwork for

addressing systemic challenges • Strengthening community oversight

mechanisms in public facilities and improve providers’ respect and kindness to their clients

AcknowledgementCo-researchers and contributers Peter Binyaruka Laura Hanselim Irene Mashasi Ikunda Njau Josephine Borghi Masuma Mamdani Siri Lange

Funders Norwegian Research Council (GLOBVAC) RESYST