In Fall 2017, practitioners, consultants, program managers, policy makers and researchers convened in Antwerp to advance the agenda of improving how Performance Based Financing (PBF) programs pay for family planning services. In the follow-up of the meeting, working groups were set up to identify better quality of care indicators. This collaborative work, which mobilized fifty experts, is now synthesized in a report. — By Bruno Meessen
Over the past 15 years, PBF has gained prominence in global health; today, it is implemented in around 30 countries. PBF is a mechanism by which health facilities are funded on the basis of their performance, traditionally measured in terms of volume and quality of services. A key feature of PBF is its potential flexibility as a strategic purchasing instrument: on the basis of new knowledge and evidence, it is possible to adapt how performance is measured and rewarded. In an ideal world, such self-reflection and adaptation would be done regularly by PBF programs. Yet, national program managers have limited time and support for this undertaking.
The meeting “Improving quality of care measurement of family planning in Performance Based Financing systems” was organized as a first step in making a collective effort to assist countries in the updating of their PBF indicators. The meeting focused on a very specific area: family planning (FP), given the need and opportunity to align performance incentives for FP services in PBF programs with intended health outcomes of beneficiaries.
Adopting a new perspective
At the meeting, there was a strong consensus among participants that existing approaches for quality of care for FP need to be updated in most PBF programs. A multi-country review showed that PBF programs are very similar in their measurement and incentivization approach – several important dimensions are currently not measured.
The encounter between PBF and FP experts was very fruitful. FP experts presented the rights-based approach (RBA) to PBF experts. We all agreed that bringing PBF programs within an RBA would be beneficial to populations and to PBF programs themselves: one cannot be wrong by linking better a strategy with a human rights framework. For instance, the current focus of PBF programs on universal health facilities only entails that we fail to reach some specific groups such as adolescents. This has to change.
At the meeting, we have learned about the latest developments in the science of quality measurement. Together, we have identified six areas where there was a need for some extra collective work.
A dialogue between PBF and Sexual Reproductive Health programs is needed in many countries. Our report aims at informing parties involved in this dialogue by putting forward new approaches on how to measure and reward quality FP services.
Our proposition is organized into six main dimensions: client experience, staff technical competence, structural inputs, outputs and outcomes, rights-based approach and equity. We have also organized the indicators in three priority classes. Our recommendation to countries indeed is not to take all the 13 indicators. We anticipate that in some countries, some indicators will not be possible.
To facilitate choices, we provide, for each indicator, a motivation, a definition, a strategy for data collection, one for data analysis and guidance as for the payment rule. We also identify some cross-cutting issues to take into account at the design or implementation stages.
There will be some operational challenges to update indicators in a PBF program. Several are identified in the report. A prospective implementation research program focused on enablers and barriers PBF & Family Planning at country level would be welcome. Other implementation research gaps identified by the participants include effects of PBF programs on quality of care, equity and provider bias.
A general recommendation to countries is to adopt the RBA approach and take equity lenses to critically assess their PBF programs. We recommend program managers to pay more attention to user experience, a critical aspect for FP. The Method Information Index, presented in the report, captures a major outcome of quality FP counselling. At least one indicator should be introduced to measure the knowledge and skills of FP providers. We recommend the vignette approach. At least one indicator should correctly capture the availability of the method mix to be delivered by the health facility. In countries where the interbirth interval is too short, we also recommend the introduction of an extra fee for each woman adopting a FP protection within the six weeks after delivery. This would constitute a relevant outcome indicator for postnatal services. We also recommend a similar extra fee for each FP adoption by a young people or a person from the poorest socio-economic group. At the end of our report, there is a full list of recommendations targeting the PBF programs, their partners, the research community and CoP facilitators.
We hope that this report will be helpful. All your feedbacks are welcome. We are grateful to the 50+ experts who have contributed to this work.
This report is the product of a working group led by Bruno Meessen, Tamara Goldschmidt, Ben Bellows and Moazzam Ali. Members of the working group are listed here. The Antwerp meeting and its follow-up benefited from the support of the Institute of Tropical Medicine, Antwerp and Blue Square, Brussels. Activities were co-funded by the Belgian Development Cooperation and the UNDP-UNFPA-UNICEF-WHO World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO).