This ppt presents some reflections on the theories of change of PBF

1. Some reflections on PBF theory of
change and Quality of Care
ToC working group (Eric Bigirimana, Peter Eerens, Rena
Eichler, Bruno Meessen, Paula Quigley)
Improving quality of care measurement of family planning
in Performance-Based Financing system
Antwerp, September 14, 2017

2. Starting point: PBF
• We have learned a lot about PBF, there is still
so much to learn
• PBF often works, but sometimes not
• Sometimes, a gap between what is planned
and what is implemented, but probably not
always
• PBF ToC: often more complex than initially
thought – there may be more prerequisites,
contextual factors, some still unidentified…

3. Starting point: PBF & QoC
• QoC is a huge challenge in LMICs
• Low QoC affects effectiveness of PBF programs
– examples
• A major learning agenda for the PBF CoP – this
meeting is a first step
• With Family Planning, we will only touch some
dimensions and determinants of QoC (fine!)

4. Starting point: QI
• Quality Improvement is not just a matter of
measuring well (checklist)
• It is also (and more fundamentally) about
much more: culture, organisational setup,
management, resources, processes, behaviors,
technology…

5. Quality Improvement framework (FP)
EpidemiologicalCommunicationSocio-cultural
Dimension
Information sharing
Structural/Organizational
dimension
Technical/ Clinical dimension
Relational dimension
PERFORMANCE/
Quality of care
Environmental
Evidence Based Practices/
MedicineBehavioral dimension
Work culture
Source: Dr Eric Bigirimana, BREGMANS Cons.& Research
Design/
Attractiveness
BREGMANS
Consulting & Research

6. WHAT IS THE THEORY OF CHANGE OF
PERFORMANCE BASED FINANCING?

7. Definition of RBF
• Performance incentives are transfers of money or
goods conditional on taking a measurable action
or achieving a predetermined performance
target. (Rena Eichler 2009)
• RBF: A cash payment or non-monetary transfer
made to a national or sub-national government,
manager, provider, payer or consumer of health
services after predefined results have been
attained and verified. (Musgrove 2011)

8. PBF CoP (7/2010)
• Performance-Based Financing is a holistic approach with a result
orientation defined as financing based on both quantity and quality of
service outputs. This approach entails making health facilities
autonomous agencies that work for the benefit of health related goals
and their staff. The effectiveness can be enhanced by demand-side
interventions such as CCTs, vouchers schemes, equity funds and
Community Based Health Insurance programs. It is also characterized by
multiple performance frameworks for the regulatory functions, the
performance purchasing agency and community empowerment.
Performance-Based Financing applies market forces but seeks to correct
market failures to attain efficiency gains. PBF at the same time aims at
cost- containment and a sustainable mix of revenues from cost-recovery,
government and international contributions. PBF draws from micro-
economic, systems analysis, and public choice and new public
management theories. PBF continuously seeks to test these theories
through empirical research and rigorous impact evaluations which lead
to best practices”

9. The principal-agent model
The principal measures
some outputs / process /
outcomes , he rewards or
sanctions accordingly
(Hypothesis:
homo oeconomicus)
Standard questions : Does it
work? If not, does the
principal measure the right
thing? Does he pay enough?
Should the checklist include
other indicators?

10. The principal-agent model +
Variation with other
behavioural assumptions.
(bounded rationality, behavioral
economics…)
You recognize that there are
psychological biases,
interpretation issues…
Questions : Is the contract and
the checklist intelligible by the
health staff? Are the incentive
structure in line with human
behaviours? Would the staff be
more responsive to the
sanction instrument?...

11. PBF as ‘glue’ (P-A++)
Dimitri Renmans – Dar-e-Salaam 11/2015
PBF as an enforcement
mechanism to allows other
ToC of the health system to
work
Examples:
- Availability of funds at the
frontline (in a fair way)
- Accuracy of routine data
- Communication about
what matters
Question: is it possible to get
these benefits in a more cost-
effective manner?

12. PBF as ‘yeast’
Jean Claude Taptué (22/9/2016 on the way to Marondera)
PBF enables other discrete
actions by managers
Examples:
- A good manager will
quickly seize PBF as an
instrument to bring its
facility/district to a higher
level
Hypothesis: there are some
necessary conditions for PBF
to work
Questions: what are these
conditions? How to favour
their emergence, at district
and national level?

13. PBF is probably all of that
1. We must recognise this multiplicity of
channels and our relative ignorance on the one
which plays the most (or on their interplay).
2. Both our action and research should better
recognize this multiplicity of channels

14. PBF: changes at different levels

15. PBF AND CHANGE MANAGEMENT

16. PBF to trigger change
• A catalyst towards
comprehensive health
care reform
• Questions: study health
system effects, focus on
the next move
→ Dar-e-Salaam 11/2015
Meessen, Soucat & Sekabaraga
WHO Bulletin 2011

17. The challenge of changing PBF
• PBF is like an operating system: it
is a systemic intervention which
interacts with the different
building blocks of the system
• Rigidities to change PBF, to revise
indicators
• Questions: how can we enhance
the use of PBF by its steward and
its partners? What are the barriers
for updating indicators?

18. IMPLICATIONS

19. Implications on action
The example of quality of care:
• If you believe in the Principal-Agent +, you
may want to focus on measuring and
rewarding a few indicators of quality of care.
• If you believe in ‘glue’ & ‘yeast’, you may want
to measure and reward as many QoC indicator
as possible (long checklist) + build an interface
to empower district managers + equip them
with (non-PBF) management techniques.

20. Implications on research
• According to the ToC, you will study different
interventions
• You may focus on different phenomena:
– Direction 1 : indicators which capture the conversion
of the health facility staff to quality improvement;
indicators which impact outcomes.
– Direction 2: indicators which captures leadership,
action points taken by district managers…

21. Measuring quality of family planning
• Our pre-meeting intuitions:
Keep dimensionality under control
And thus, focus on key indicators
Think “multiple determinants”,
And thus, identify them and assess relevance of their measurement as well
Acknowledge complexity, political contexts and other unknowns
And thus, avoid too restrictive directions
Acknowledge variation across contexts
And thus, find ToC(s) with best contextual fit
QI is also about behavioral change
And thus, leave PBF comfort zone and embrace BC
Quality and quality perception evolves
And thus, map barriers to updating FP indicators
So much research remains to be done
And thus, all the above should enter agenda for implementation research

22. Last reflection
• Peter: “Health systems are complex systems.
Everything is connected: causality goes
through many channels. A ToC is actually a
reflexive way to navigate this complexity ; a
ToC tells as much about ourselves as about
the reality under analysis. Our data should
trigger action, much more than measure
everything”.