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For- Performance Across Health Facilities in Tanzania Original research BMJ Glob Health: first published as 10.1136/bmjgh-2020-002326 on 30 May 2020. Downloaded from Understanding efficiency and the effect of pay- for- performance across health facilities in Tanzania 1 2 Peter Binyaruka , Laura Anselmi To cite: Binyaruka P, ABSTRACT Key questions Anselmi L. Understanding Background Ensuring efficient use and allocation of efficiency and the effect limited resources is crucial to achieving the UHC goal. What is already known? of pay- for- performance Performance- based financing that provides financial across health facilities in There is a room for increasing efficiency in resource incentives for health providers reaching predefined targets ► Tanzania. BMJ Global Health use across health facilities in low/middle- income would be expected to enhance technical efficiency across 2020;5:e002326. doi:10.1136/ countries. facilities by promoting an output- oriented payment system. bmjgh-2020-002326 Healthcare financing reforms have the potential to However, there is no study which has systematically ► stimulate efficiency in resource use including those assessed efficiency scores across facilities before and Handling editor Valery Ridde focusing on output-based financing (eg, pay-for - after the introduction of pay- for- performance (P4P). This performance (P4P)). Received 20 January 2020 paper seeks to fill this knowledge gap. Revised 15 April 2020 Methods We used data of P4P evaluation related to What are the new findings? Accepted 19 April 2020 healthcare inputs (staff, equipment, medicines) and outputs ► The technical efficiency score from 150 facilities in (outpatient consultations and institutional deliveries) from Tanzania ranged between 40% and 65% for hospi- 75 health facilities implementing P4P in Pwani region, and tals and health centres, and lowest around 20% for 75 from comparison districts in Tanzania. We measured dispensaries. technical efficiency using Data Envelopment Analysis and ► Higher efficiency scores were significantly associ- obtained efficiency scores across facilities before and ated with the level of care provided (hospital and after P4P scheme. We analysed which factors influence health centre) and wealthier catchment populations. technical efficiency by regressing the efficiency scores ► There is no evidence that P4P improved efficiency over a number of contextual factors. We also tested the on average, but might marginally improved among impact of P4P on efficiency through a difference- in- public facilities only. differences regression analysis. http://gh.bmj.com/ Results The overall technical efficiency scores ranged What do the new findings imply? between 0.40 and 0.65 for hospitals and health centres, ► Facilities can still improve efficiency, but the service and around 0.20 for dispensaries. Only 21% of hospitals delivery processes at the health facility level and the and health centres were efficient when outpatient effect of incentive schemes need to be better under- consultations and deliveries were considered as output, stood to determine how to improve efficiency. and <3% out of all facilities were efficient when outpatient ► Large share of technically inefficient facilities sug- on September 29, 2021 by guest. Protected copyright. consultations only were considered as outputs. Higher gests that most facilities (especially dispensaries) efficiency scores were significantly associated with the are not operating in their full capacity or significantly © Author(s) (or their level of care (hospital and health centre) and wealthier wasting resources, perhaps due to poor healthcare employer(s)) 2020. Re- use catchment populations. Despite no evidence of P4P seeking culture. permitted under CC BY-NC. No effect on efficiency on average, P4P might have improved commercial re- use. See rights efficiency marginally among public facilities. and permissions. Published by BMJ. Conclusion Most facilities were not operating at their burden of diseases (communicable and non- full capacity indicating potential for improving resource 4 5 1Health System, Impact communicable diseases) and relatively poor 6 7 Evaluation and Policy, Ifakara usage. A better understanding of the production process at health system performance. Despite the Health Institute, Dar es Salaam, the facility level and of how different healthcare financing efforts to ensure more funding are allocated reforms affects efficiency is needed. Effective reforms Tanzania to the health sector, resources are still limited 2Health Organisation, Policy should improve inputs, outputs but also efficiency. and ensuring they are used efficiently and and Economics, Centre for 8 Primary Care and Health equitably is crucial to achieve UHC goals. Services Research, University of In 2010, the World Health Report estimated Manchester, Manchester, UK INTRODUCTION about 20%–40% of health resources are being Low/middle- income countries (LMICs), espe- wasted globally due to inefficient and inequi- Correspondence to 1 9 Dr Peter Binyaruka, Ifakara cially in sub-Saharan Africa, are constrained table use of resources. Indeed, countries’ Health Institute, Dar es Salaam, in achieving universal health coverage health systems need not only more resources Tanzania; pbinyaruka@ ihi. or. tz (UHC) by limited resources,1–3 double for health but also efficient use of available Binyaruka P, Anselmi L. BMJ Global Health 2020;5:e002326. doi:10.1136/bmjgh-2020-002326 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2020-002326 on 30 May 2020. Downloaded from resources. Efficiency can either be technical efficiency and timely, as it adds to a limited evidence on the asso- (minimum amount of resources used for a given level ciation between P4P and efficiency, which we suggest of output or maximum amount of output produced for policy- makers should consider when making decisions a given level of resources) or allocative efficiency (how with the implementation of P4P in low- resource settings resource inputs and their prices are combined to produce like Tanzania. a mix of different outputs).9 Pay-- for performance (P4P) schemes, which provide Study setting financial incentives for health workers and/or facilities This study took place in Tanzania, a low-income country reaching predefined targets, are gaining popularity in in East Africa. Most facilities (70%) in Tanzania are LMICs as a means of improving facility performance government owned. The public health system has a hier- and health system strengthening.10–13 Although there archical administration and is organised in a referral is a variation across schemes, P4P incentives are typi- structure, with dispensaries and health centres providing cally rewarded to facilities or healthcare providers after primary care and hospitals providing secondary and the achievement of quantity and quality targets. These tertiary care.29 The health system is decentralised, payments are used for facility improvement as well as whereby local managers are given power to plan and additional bonus to staff salary.14 15 So, while incentiv- manage resources.30 Like in other LMICs, most health ising output improvement, bonus payments to facilities facilities in Tanzania are facing shortage of staff,31 drugs can also contribute to the improvement of infrastructure and supplies.32 33 Health financing is highly fragmented and to drugs and supplies availability, among others. with many sources including general taxation (26%), Some P4P schemes also offer an initial payment to facil- donor support (41%), out-of- pocket payments (23%) ities enrolled in the scheme to expand their capacity and health insurance contributions (8%).34 35 About 32% for service provision. Since P4P is an output-oriented of Tanzanians are covered by health insurance—ie, 8% financing strategy aimed at increasing the provision of as public servants mainly through National Health Insur- targeted services, one would expect P4P to enhance effi- ance Fund, 23% as informal workers through Community ciency in service delivery. For instance, P4P can improve Health Fund (CHF) and 1% from private insurance.36 In allocative efficiency by incentivising an optimal mix of 2018/2019, about 9% of total government expenditure services that maximises health improvements, and it can or total budget was allocated for health (below the Abuja improve technical efficiency by increasing the quantity Declaration Target of 15%).36 Tanzania has introduced and quality of services produced for a given amount of various healthcare financing reforms in an effort to move inputs.11 toward UHC, including fiscal decentralisation through There is a growing body of evidence evaluating the direct health facility financing,37 38 improved CHF39 impact of P4P in LMICs. However, most of these studies and national roll- out of P4P, also called results- based have focused on assessing the effects of P4P on service financing programme.40 coverage,12 16 quality of care17, equity in service delivery In January 2011, Tanzania introduced a P4P pilot http://gh.bmj.com/ and resource distribution,18–20 and on facility inputs, such scheme in Pwani region before national roll- out, with as human resources21–23 and medical commodities.24 25 the aim of improving maternal and child health (MCH) Many P4P evaluations indicate mixed results, with notable services.41 All health facilities providing MCH services in increases of incentivised service delivery indicators. The the region were eligible to implement the scheme. P4P current literature, however, shows relatively little
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