Paying for Performance in Health: Guide to Developing the Blueprint

P4P BlueprintRena Eichler and Susna De

Pay for performance (P4P) is an innovative approach that explicitly links financial investment in health to health results. While the P4P concept seems relatively straightforward, the mechanics of its implementation need to be planned very carefully to elicit the desired behavior change in a given country. To facilitate this planning, USAID through its Health Systems 20/20 project has developed the P4P Blueprint Guide. Intended for country health program managers, including those representing government, non-government, and donor agencies, this Guide offers the reader a systematic framework to document and structure his/her thought process, rationale, and ultimate decisions made when designing a P4P initiative. In following each recommended step of the Guide (facilitated by technical support from experienced P4P implementers), the user is alerted to factors and issues that can influence the success of a P4P scheme.

Upon completion of the Guide, the user will have produced a “blueprint” design or “game plan” for introducing P4P to his/her program area/country. The suggested approach outlined in this Guide is based upon a successful tool used in Africa’s first regional Pay for Performance workshop sponsored by USAID. Some of the participating countries that developed blueprints have gone on to implement their P4P designs – turning their ideas into reality. In addition, the Guide draws upon the lessons learned from P4P implementation in developing countries.

(Available on the HS 20/20 <>  website)

Health Systems Strengthening via Performance-Based Aid: Creating Incentives to Perform and to Measure Results

HSS via PBARena Eichler and Amanda Glassman

The new global health partnerships, such as the Global Alliance for Vaccines and Immunization (GAVI Alliance), the Global Fund for AIDS, TB, and Malaria (GFATM), and UNITAID have fundamentally changed the landscape and scale of funding for global health initiatives since 2000. As many more billions of dollars flow into these organizations and through traditional bilateral and multilateral funders of health assistance, strengthening the connection between the financial flows and results increases in importance. The experience with performance-based assistance for health projects has increased in recent years, presenting the opportunity for donors to consider some of the lessons and to build them into their own programs. This paper reviews some of the experience and derives lessons for shifting more funding into performance-based instruments.

(Available on the Brookings Institution <; webpage)

Going to Scale with Performance Based Payment: Six Years of Supply Side Results in Haiti

PBI for healthRena Eichler, Paul Auxila, Uder Antoine, and Bernateu Desmangles

USAID launched a project in 1995 to deliver basic health services in Haiti. The project began by reimbursing contracted NGOs for documented expenditures or inputs. In 1999, payment was changed to being based partly on attaining performance targets or outputs. The project also provided technical assistance to the NGOs, along with opportunities to participate in an NGO network and other cross- fertilization activities. Remarkable improvements in key health indicators have been achieved in the six years since payment for performance was phased in. Although it is difficult to isolate the effects of performance-based payment on these improved indicators from the efforts aimed at strengthening NGOs and other factors, panel regression results suggest that the new payment incentives were responsible for considerable improvements in both immunization coverage and attended deliveries. Results for prenatal and postnatal care were less significant, perhaps suggesting a strong patient behavioral element that is not under the influence of provider actions.

(Available on the Center for Global Development <;  website)

Can Incentives Strengthen Access to Quality Family Planning Services? Lessons from Burundi, Kenya, and Liberia

Lindsay Morgan

Can performance-based incentive (PBI) programs – programs that reward the delivery of outputs and outcomes with financial incentives – stimulate quality family planning (FP) service provision and enable women to access FP services? Or is incentivizing FP too riddled with risk, too liable to encourage providers to coerce patients or to cause patients to feel pressured to accept an FP method?

This paper discusses what are the best ways for rewarding quality FP counseling and service provision in PBI, and shows how three countries – Burundi, Kenya and Liberia – are doing it. It covers the best types of indicators to link to incentives; approaches for supporting overall quality improvement, including FP; and ensuring high-quality counseling, whether in facilities or in communities where women live.

Though there is a risk that poorly designed PBI programs could lead to distortions and damage informed choice, this paper shows that well-designed PBI programs can have the opposite affect: they can improve the quality of FP service provision, respect patient choice, and empower women and their families.

A Rough Guide to Community Engagement in Performance-Based Incentive Programs: With Lessons from Burundi, Indonesia, and Mexico

Rough guide to community engagementLindsay Morgan

Engaging and empowering communities to enhance accountability is a growing trend in the health sector, mirroring a growing interest in health sector governance more broadly. This guide aims to help policymakers and program managers assess whether engaging communities makes sense in the context of the performance-based incentive (PBI) programs they support; determine what is the best approach or mechanism for such engagement; and how to mitigate the risks. PBI, as with bottom-up social accountability mechanisms, aims to fix broken accountability relationships by providing payers of health services tools to hold providers accountable through provision of incentives for verified increases in the quantity and quality of health services.

Lessons and recommendations in the guide are based on part on detailed research conducted in three countries implementing very different PBI programs: Burundi, Indonesia and Mexico. Among the challenges highlighted in this guide is the need to balance cost savings with ensuring these important functions are robust. There are risks of elite capture and exclusion, and tensions between the goals of Community Engagement– for example, the desire for Community Engagement to be inclusive and representative – and the needs of the programs, which requires individuals and entities with skills, experience, and independence/objectivity.

Community-Based Monitoring Programs in the Health Sector: A Literature Review

Kevin Croke

As attention on global health grows, along with mounting evidence showing weak links between public sector health spending and health outcomes, the problems of governance in the heath sector have gained new relevance for policymakers. This review summarizes the literature on one strategy to improve health sector governance: community-based monitoring programs. It presents prominent examples of community-based monitoring approaches, highlights common design features and parameters, discusses challenges faced by these programs, and outlines knowledge gaps and areas of future focus. In particular it focuses on two recent successful community-based health sector monitoring projects, in India and in Uganda, and suggests that they provide promising models for future programs.

Community Engagement and Performance-based Incentives: The View From Burundi

Karishmah Bhuwanee and Lindsay Morgan

This case study, one in a series exploring community engagement and PBI, discusses the ways in which Burundi’s performance-based incentive (PBI) program has (or hasn’t) increased social accountability by contracting local community-based organizations to conduct verification and gauge patient satisfaction with services.

We describe the nuts and bolts of how this mechanism is implemented, and measure it against two essential elements of effective CE: access to information and channeling views/collective action.

The bottom line: combining bottom-up pressure and the top-down accountability strategy of PBI has significant potential to enhance social accountability, especially in a country like Burundi, where PBI has been institutionalized and scaled up. But CBO verification raises questions of independence and patient privacy, and engaging them does not necessarily foster community-wide empowerment and participation.

Community Engagement and Performance-Based Incentives: The View from Indonesia

Lindsay Morgan, Derick Brinkerhoff, and Mohammad Najib

The economic and social fabric of Aceh were shattered by the December 2004 tsunami and the decades of secessionist war that preceded it. In response, the Australian Agency for International Developed launched a governance program aimed at fomenting citizen participation and empowerment in order to spur governments to deliver services to improve living standards. This case study, one in a series exploring community engagement and performance-based incentive (PBI), analyzes a PBI approach that was folded into the ambitious program. It finds the PBI element needed strengthening: the incentive payment was conditional on achievements outside the control of the incentive recipient, and the system to verify results was weak But as a mechanism for enhancing citizen empowerment and social accountable, the program had marked strengths. Among them, the provision to communities of objective service delivery data set against national standards warrants mentioning—it empowered communities to prioritize their needs and strengthened the impact of their engagement with facilities. From a PBI perspective, involving communities in setting the priorities of facility performance contracts is novel and potentially powerful.

Community Engagement and Performance-based Incentives: The View From Mexico

Katherine Scaife Diaz

This case study, one in a series exploring community engagement and PBI, discusses the ways in which Mexico’s performance-based incentive (PBI) program, Oportunidades, has (or hasn’t) increased social accountability by engaging program beneficiaries, known as vocales, to oversee program administration at the local level.Oportunidades, a conditional cash transfer program, has received attention and acclaim for its success combating poverty and poor nutrition. This case study traces the origin of the vocales, describes their roles and responsibilities, and examines whether they are an appropriate mechanism for program administration. The study also considers how engaging communities through vocales might enhance social accountability and citizen empowerment.

The case finds that the vocales are a low-cost mechanism for providing a local information source to poor, marginalized, and indigenous Oportunidades beneficiaries. It is unclear that the vocales stimulate wider community empowerment or participation, but the mechanism does appear to strengthen and empower the vocales themselves. However, vocales? election, training, and supervision remain disorganized, and there is a tension in the program between supporting new community leadership and ensuring that the vocales do not overstep their role.

In Brief: Performance-based Incentives in Africa: Experiences, Challenges, Lessons

Lindsay Morgan and Rena Eichler

Performance-based incentive (PBI) programs are in various stages of development in countries across sub-Saharan Africa. Many programs are pilots, but some countries have integrated PBI into their health systems and scaled up programs nationally.

Performance incentives offered to teams of health workers, subnational levels of government, contracted nongovernmental organizations (NGOs), or patients, among others, aim to motivate the health workforce, focus attention on (and provide demonstrable evidence of) results; strengthen information systems; build local capacity to manage and deliver health services; and, of course, improve health outcomes.

This brief traces the evolution of PBI programs in sub-Saharan Africa and shares evidence on its impact on health and health systems as well as the gaps in knowledge and practice.

It is based on a longer report <>  of the same name.