The IHPN Network organized a pre-conference on “Pay-for-Performance and Performance-Based Aid: at the crossroads?” at Clermont-Ferrand. You will find hereunder the summary of our discussions.
Experience with pay-for-performance and performance-based financing in middle and high income countries
Winnie Yip (Oxford University) presented on P4P reform in China that begun in April 2009. The aim of the reform was to contain costs and incentivize providers to prescribe the correct mix of drugs and services. After the reform, about 30% of the providers’ payment is based on performance. However, this remains so on paper and in reality the methods to calculate bonuses are very complicated and lead to limited variability (scores are consistently very high). Questions remain open about the real effectiveness of the scheme.
Yi-Ling Chi (OECD) presented the recent OECD review of P4P in some OECD countries. The design of these schemes varies broadly between countries, as much as results.
Joseph Kutzin (WHO) focused on Central and Eastern Europe and in particular the case of Kyrgyzstan, where PBF was introduced to substitute informal payments that (in absence of a mechanism to reimburse providers) were asked also to people formally exempt from user fees.
* One important point regarded the reasons of the introduction of P4P. In most low income countries, the issue to address is that health services are under-produced. On the contrary, in most middle and high income countries, the problem addressed with P4P is cost containment and the rationalization of the provision of care (such as the case of prescription of unneeded, expensive drugs and services). This difference in the reasons for implementing P4P, affects the design and in some cases the effectiveness of the scheme.
* Other point of the discussion regarded equity and how the schemes can be designed to promote it, in particular between rich and poor regions.
* The cultural and social context and its influence on the effectiveness of the scheme was also discussed. One particular aspect regarded the role of civil society and local NGOs. In some countries, these may not exist at all, or not really represent the population. However, the “community” is still present and has been involved in some schemes (for example, in China, where people from the community are chosen to be in the health insurance board).
Performance-based Aid (PBA): our experience, our grand plan
This session consisted in two parts. Firstly, five presenters illustrated the cases of existing or planned PBA schemes (GAVI, Global Fund and SM2015) or proposed possible alternative models (TrAid+ and Cash on Delivery).
Performance Based Funding of the Global Fund. Kirsi Viisainen
Salud Mesoamérica 2015 initiative. Rena Eichler
* During the discussion, one interesting question (to which an answer is difficult to give) regarded the possibility of “cascading” effects, once a government or a ministry is rewarded based on performance. Will the effects trickle down to change the civil servants’ and then the providers’ behaviour?
The second part consisted in a panel of experts (Agnes Soucat from the African Development Bank, Luis Rusa of the Rwanda Government, Jonathan Glennie from the Overseas Development Institute, UK, and Guy Stallworthy of the Gates Foundation), that discussed the issues of “performance-based aid: a paradigm shift in the aid sector?”.
Jonathan Glennie highlighted that PBA represents a new paradigm and a positive change, as it moves away from “process based” aid. However, it’s not a revolution! PBA may work in some contexts and not work in others. Luis Rusa said, from the perspective of an African government, that PBA represent an opportunity for both the governments and the donors to align their objectives and achieve results. But it’s also important to go beyond the funds-results relation, and understand what the complex reasons that determine the results are. Agnes Soucat mentioned three points: (1) this is not a “aid” debate, but a discussion over public sector management and a reflection on how to obtain more equitable, effective systems; (2) PBA responds to a call for accountability of citizens in all parts of the world (under everyone’s eyes as the “arab spring” unfolds); (3) it’s not a quick fix, but demands specific decisions for specific contexts.
See also Jonathan’s blog in the Guardian related to the panel: http://www.guardian.co.uk/global-development/poverty-matters/2011/may/13/cash-delivery-future-results-based-aid