J E D F R I E D M A N , A S H I S D A S , R O N A L DM U T A S A , G I L S H A P I R A , D A M I E N D E

W A L Q U E , E E S H A N I K A N D P A L , A N E E S AA R U R , H A N G U Y E N , A N D M A N Y O T H E R S

Quality of healthcare in Results Based Financing (RBF) projects

General features of RBF program design

Rapid growth in number of World Bank RBF projects galvanized by grant financing provided by UKAID and Norway

Diverse set of programs, but all involve (a) the introduction of a pay-for-performance scheme at some level of

health provision and/or

(b) demand side financing for health

Pay-for-performance most commonly involves: A fee-for-service introduced for priority maternal and child health

services at the primary clinic level

Enhanced monitoring, supervision, and verification to ensure that payments represent actual services delivered

Typically these pilots are large scale, implemented by governments, and with dedicated funds for evaluation

Growth in evaluated RBF projects

33 impact evaluations: 23 approved designs and 10 in pipeline

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Global reach of RBF evaluation portfolio

How is QoC currently addressed by the typical RBF project?

The primary goal of the vast majority of RBF projects is to increase utilization of key MCH services

Increasing access doesn’t necessarily improve health if quality is poor

So most projects also:

Attempt to assess clinic-level QoC through a balanced scorecard approach (BSC)

Scale the quantity-based payments proportional to overall quality score

The BSC is – typically – focused on structural quality as that is relatively easy to observe by peers

Example of primary clinic BSC (Zimbabwe)

Zimbabwe experience with 1st generation BSC

• Promoted a culture of peer review of clinic quality however…

• Focus on register completion (“# columns checked”) rather than processes of clinical care (specific clinical interventions)

• Heavy emphasis on “structural quality” (e.g. appearance of the facility, medications, supplies, staffing)

• Poorly defined clinical quality indicators (e.g. numerator not clearly defined), inter-rater reliability issues

2nd generation BSC: Selecting standards and defining quality of care measures

Involved local and international experts to:

Review country standards against global evidence ideally iterative process as evidence is constantly changing

Distill standards into minimum “intervention bundles”: focused attention on essential high-impact interventions

Illustrative quality of care process measures based on minimum standards: % cases adherent with standards – “all or nothing adherence” (e.g. %

PPH cases managed per minimum standard; % cases pediatric pneumonia treated per standard)

Average % adherence with minimum standards (e.g. average % adherence with newborn sepsis case-management standards; N=30 cases)

Illustrative quality measure: Quality of partogramcompletion

Quality Measure Operational Definition

% partograms in last quarter

completed per standard

NUMERATOR: Number partograms

documenting cervical dilation, maternal BP,

pulse, temperature at admission and at least

every 4 hours until delivery

DENOMINATOR: Total number of

partograms reviewed

Considerations for incentivizing QoC I: Which measures implementable at scale

Structured direct observation

Patient interviews & questionnaires (e.g. exit interview; household survey)

Death (and near-miss) audits

Simulations (provider competence)

Provider knowledge/problem-solving (e.g. vignettes/case studies)

Routine information systems (e.g. facility chart & register audits; routine health information system)

-Probably not: standardized patients, video review

Considerations II: routine versus complications care

Easier to measure routine best practices relevant for every patient: often simple intervention for which a “box” can be checked in a standard record (e.g. ENC, AMTSL; immunization)

More difficult to measure quality of complications care

Timely accurate diagnosis

Stabilization and successful timely referral (primary facility)

Prompt and ongoing treatment/monitoring (hospital)

Discharge planning and follow up

Zimbabwe: Beyond structural incentives

Supporting MOH to draft and implement national/regional QI strategy…..align RBF with strategy

Supporting MOH to introduce quality indicators into HMIS…..strengthening HMIS

Innovations to introduce continuous quality improvement and rigorously evaluate P4Q alone vs.

P4Q plus continuous quality improvement (CQI) vs.

P4Q plus CQI plus incentives for management of quality

Additional slides

Below

Zimbabwe Indicators Example

Indicator Measuring the Indicator

Designated nurse triages patients in OPD waiting area during all clinic shifts according to standards., documenting at a minimum in patient’s card and/or clinic register: temperature, respiratory rate, pulse, weight, BP (if adult)

Verify that a nurse is designated to triage patients in OPD waiting area for every OPD session in the week.Check OPD cards of at least 5 patients (or all patients if < 5 patients) on waiting bench in OPD area to verify that age, weight, BP (if adult) and temperature, respiratory rate and pulse have been recorded.

% children treated for pneumonia in last quarter correctlytreated

-Oral Amoxicillin 50mg/kg divided three times per day x 7 days; caretaker counseling and follow up specified ORreferral to hospital if any signs of respiratory distress

Of the total child pneumonia cases treated in past month (see above cell), calculate: % pneumonia cases in past month documeting adherence with best treatment practices.

Numerator: # of pneumonia cases treated in past month treated with oral amoxicillin 50-90mg/kg divided twice per day x 7 days and/OR referral to hospital if signs of respiratory distress at any time.

Denominator: Total # of pneumonia cases reviewed

How close does this approach get to addressing QoC?

Well, how do we define quality of care?

If high quality care is……

Effective: Adherent with evidence-based standards Safe: does not harm patientsClient centered: Respectful of patient needs, values & preferencesEquitable: Does not vary in quality because of personal characteristics (gender, ethnicity, SES, etc)

IOM, 2001, Crossing the Quality Chasm

Pre-eclampsia/Eclampsia chart audit tool for primary facility

Charts

Evaluation 1 2 3 4 5

1. Blood pressure (BP) recorded

1. Gestational age (GA) recorded (per one of criteria indicated in

GUIDE)

1. Urine protein quantified (dipstick +, ++, +++)

1. Danger signs assessed (see chart review guide)

Diagnosis pre-eclampsia or eclampsia recorded if

criteria met1. DBP > 90 and at least 2+ proteinuria pre-eclampsia (+ seizure if

eclampsia)

First Treatment and referral if primary facility

1. 4 gm loading dose of MgSO4 IV ; monitor for toxicity (reflexes,

urine output, respirations)

1. If GA < 34 weeks administer antenatal corticosteroids

1. Transfer with IV access (and provider if possible)