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Policy Research Working Paper 8951 Public Disclosure Authorized Incentivizing Quantity and Quality of Care Evidence from an Impact Evaluation of Performance-Based Public Disclosure Authorized Financing in the Health Sector in Tajikistan Tashrik Ahmed Aneesa Arur Damien de Walque Gil Shapira Public Disclosure Authorized Public Disclosure Authorized Development Economics Development Research Group & Health, Nutrition and Population Global Practice July 2019 Policy Research Working Paper 8951 Abstract This paper presents the results of an impact evaluation of and control standards, availability of equipment and med- a performance-based financing pilot in rural areas of two ical supplies, provider competency, provider satisfaction, regions of Tajikistan. Primary care facilities were given and even some elements of the content of care, measured financial incentives conditional on general quality and the through direct observations of provider-patient interactions. quantity provided of selected services related to reproductive, While the communities in the performance-based financing maternal and child health, and hypertension-related services. districts reported higher satisfaction with the local primary The study relies on a difference-in-difference design and care facilities, and despite the improvements in quality, the large-scale household and facility-based surveys conducted findings suggest moderate effects on utilization: among the before the launch of the pilot in 2015 and after three years incentivized utilization indicators, only timely postnatal of implementation. The performance-based financing pilot care and blood pressure measurements for adults were sig- had positive impacts on quality of care. Significant impacts nificantly impacted. are measured on facility infrastructure, infection prevention This paper is a product of the Development Research Group, Development Economics and the Health, Nutrition and Population Global Practice. It is part of a larger effort by the World Bank to provide open access to its research and make a contribution to development policy discussions around the world. Policy Research Working Papers are also posted on the Web at http://www.worldbank.org/prwp. The authors may be contacted at [email protected]. The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the series is to get the findings out quickly, even if the presentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations, or those of the Executive Directors of the World Bank or the governments they represent. Produced by the Research Support Team Incentivizing Quantity and Quality of Care: Evidence from an Impact Evaluation of Performance-Based Financing in the Health Sector in Tajikistan* Tashrik Ahmed, Health Nutrition and Population, The World Bank and Johns Hopkins School of Public Health Aneesa Arur, Health Nutrition and Population, The World Bank Damien de Walque, Development Research Group, The World Bank Gil Shapira, Development Research Group, The World Bank Keywords: Performance-based Financing; Health; Quality of care JEL classification: I15; J13; O15. * We are extremely grateful for a fruitful collaboration with the Ministry of Health of Tajikistan. The evaluation was supported by the project implementation unit of the Tajikistan Health Services Improvement Project (HSIP), under the leadership of Mahbuba Mustafaevna. In particular, the team would like to acknowledge the work of Fatima Gaibova and Saodat Mirsaburova. Zerkalo Analytics led the data collection. For support and inputs during the study design and implementation, the team would like to thank Sarvinoz Barfieva, Mutriba Latypova, Rouselle Lavado, Kate Mandeville, Wezi Msisha, Ha Nguyen, Sabrina Qandenova, Jeanette Walldorf and Huihui Wang. This impact evaluation is funded by the Health Results Innovation Trust Funds (HRITF) at the World Bank. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the World Bank, its Executive Directors, or the countries they represent. 1. Introduction Substantial disparities in health care coverage persist in low- and middle-income countries despite the progress towards the Millennium Development Goals (Wagstaff, Bredenkamp and Buisman, 2014). These gaps exist for basic maternal and child health services, as well as for services aimed at preventing and treating non-communicable diseases. This assessment is starker if effective coverage is measured, i.e., coverage of high-quality services (Shengelia et al. 2005). There is substantial evidence that the quality of care in many low- and middle-income countries is low. Health conditions are often misdiagnosed and even when correctly diagnosed, the appropriate treatment or interventions may not be prescribed or available (Das, Hammer and Leonard 2008, Das and Hammer 2014, Kruk et al. 2018). Because of these gaps in quality of care, health outcomes improve at a slower pace than coverage rates. Confronted with limited progress, low- and middle-income countries have experimented in incentives involving a mix of salaries, budgets and bonuses linked to performance (Witters et al. 2012; Miller and Barbiarz 2013; Peabody et al. 2014; Yip et al. 2014; Sun et al. 2016). Performance-based financing (PBF) is a pay-for-performance mechanism aimed at improving effective coverage through financial incentives to health providers which reward both quantity and quality of health services delivered (Fritsche et al. 2014; Friedman and Scheffler 2016). In recent years, a growing number of prospective impact evaluations of PBF programs have been completed (Basinga et al. 2011; Bonfrer et al. 2014a; Bonfrer et al. 2014b; Gertler et al. 2014; Celhay et al. 2015; de Walque et al. 2015; Engineer et al. 2016; Friedman et al. 2016; de Walque et al. 2017; Van de Poel et al. 2016; Shapira et al. 2018). These programs have had mixed success in improving the coverage of health services. Most studied interventions managed to positively improve coverage of only some of the incentivized services and a few programs failed to show any significant improvements on coverage. There is solid evidence that PBF positively impacts quality of care (Kandpal 2017). Almost all programs were successful in improving indicators of structural quality such as facility infrastructure and availability of medical supplies. A smaller number of studies have also shown positive impacts on the content of care (Basinga et al. 2011; Engineer et al. 2016; Friedman et al. 2016). This paper presents an evaluation of a PBF pilot in Tajikistan, launched in January 2015 in selected rural districts in Khatlon and Sughd regions. Rural health centers (RHCs) and health houses receive 2 financial incentives conditional on the quantity and quality of provided services, including family planning, antenatal and postnatal care, child vaccination and growth monitoring, and hypertension. Up to 70 percent of the quarterly performance payments can be distributed as bonuses to the clinical staff, while at least 30 percent had to be reinvested in the facility. The program included multiple layers of supervision and verification by regional and national agencies and a third-party counter-verification of the performance indicators. This impact evaluation relies on a difference-in-difference design, which compared changes in outcomes between the districts implementing PBF and control districts within the same regions. Coverage rates were measured at the population level by household surveys conducted before the launch of the program and after three years of implementation. Detailed data on quality of care was collected through extensive facility-based surveys that included general facility assessments, interviews with health providers, and direct clinical observations of patient-provider interactions. The results provide evidence of substantial positive impacts of the PBF reform on many dimensions of quality of care. It increased the availability of equipment and supplies at the primary health centers. It had positive impacts on infrastructure and infection prevention and control standards, such as the availability of containers for sharps and needles in consultation rooms. We also find positive impacts on provider competency, measured through clinical vignettes. Finally, we find evidence that the improvements in structural quality and provider knowledge also translated into better content of care. For example, providers in the PBF facilities are more likely to perform key physical exams such as to measure the height and weight of children under 5. The PBF pilot had positive impacts on health providers. Their income increased by about two- thirds due to performance bonuses, and they reported higher satisfaction, especially concerning the working conditions in the facilities. Community perceptions of health providers were also positively impacted. During the follow-up survey, individuals living in PBF districts reported significantly higher perceived competency of providers and that the staff work closely with and listens to the community. Additionally,

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