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Performance Based Incentives for Quality of Care

Performance Based Incentives for Quality of Care

Performance-Based Incentives (PBI) programs in developing countries have focused on expanding access and coverage of services and addressing issues of equity. Because PBI is a relatively new area of work that stresses increased utilization of services, there has been less attention paid to assessing or incentivizing quality of care or in understanding the unintended consequences of these programs on quality of other services. The ultimate goal of this implementation research effort is to anticipate and help program implementers address quality of Essential Obstetric and Newborn Care (EONC) in the context of PBI programs. This vision recognizes that some of the current PBI programs do not yet address quality, but as new programs are developed or refined, quality will be essential to the sustainability of PBI's programs which support EONC. 
In June 2012, TRAction convened a consultative meeting on performance-based incentives and quality of maternal newborn health care in low resource settings, in order to advance the dialogue around opportunities and challenges for performance measurement and research.  Materials from this meeting can be found here.
In January 2014, TRAction and partners from the World Bank and other organizations working in the performance-based incentives and quality of care fields came together to launch a technical working group to explore how the two groups can collaborate to improve the quality of maternal newborn health care. Materials from this meeting can be found here.
In April of 2016, TRAction and the Harvard Maternal Health Task Force, in collaboration with the World Bank and USAID, convened through a two-day workshop on the role of quality within PBI programs, with a focus on implications for maternal and newborn health. Materials from this workshop can be found here.

Our Partners

  • Bocconi University Center for Research on Health and Social Care Management (CERGAS)
  • Results for Development (R4D)
  • Royal Dutch Tropical Institute (KIT)
  • ThinkWell Global
  • University of Heidelberg Institute of Public Health (IPHHD)
  • University of Malawi College of Medicine (COM)



Publications Featuring TRAction Research



Policy Briefs:

Case Studies:


Collaborative Efforts

Assessing Quality of Care in Malawi

A health worker cares for a newborn at Kochirira Health Centre in Mchinji District. Photo Credit: Uchembere Wangwiro Program
Assessing quality of care in Malawi’s Support for Service Delivery and Integration Project’s Performance Based Incentives Intervention

This study examined the process of implementing the SSDI-PBI program in Malawi, including important factors that have influenced program implementation, acceptance, and adoption. The study also measured any changes in quantity and quality of services provided, as well as changes in provider motivation and behavior. Finally, it analyzed the costs of the program compared to its attributable benefits.

Measuring Quality of Care in Kenya

A nurse writes in a logbook at a desk in the TB-HIV room of a clinic in Kenya.  © 2013 Alfredo L Fort, Courtesy of Photoshare
Developing and Applying a Quality of Care Diagnostic
PBI programs are designed around the premise that incentives can improve quantity and quality of care. In order to design effective PBI programs and incentivize improvements in certain indicators, health officials must first identify areas in which quality of care is sub-optimal. This study developed a quality of care (QoC) diagnostic tool that can be applied to readily available national data from DHS and SPA to determine which areas would be appropriate targets for PBI interventions. The study team then applied the diagnostic tool to data from Kenya's 2010 DHS and SPA surveys to measure QoC. 

Quality Instruments and Provider Behavior and Perceptions in Senegal's PBI Program

Photo of Mother and child at their home in Nigeria
Quality of Care Assessment Instruments and Provider Behavior within Senegal’s RBF Program

In 2012, Senegal's Ministry of Health and Social Affairs began piloting a results based financing (RBF) program focused on maternal and child health. Results for Development (R4D), supported by TRAction, conducted two studies aimed to: (1) enhance the primary care quality of care assessment instrument (QCAI) checklist; (2) design a secondary care QCAI with a focus on essential obstetric and neonatal care indicators; and (3) understand provider behavior and response to incentives under RBF programs. Studies were conducted as the MOH sought to integrate strategies to incentivize quality within its existing program, with particular attention to essential obstetric and neonatal care services.

Global Analysis of Quality within PBI

Women waiting at a health clinic. Photo Credit: URC.
Global Landscape Analysis of Quality within PBI Programs

This study examined how and to what extent countries are incentivizing quality of care within performance-based incentives (PBI) programs. This analysis provided program planners with a global comparison of the various approaches to defining, measuring, and incentivizing quality. Stemming from this landscape analysis, quality and quantity indicators were analyzed from 32 results-based financing (RBF) programs. The study team also produced four country case studies that illustrate the range of approaches to improving quality through PBI programs, and the successes and challenges of each. 


Results-Based Financing for MNH in Malawi

Health provider cares for mother and newborn at a health center in Dedza District, Malawi. Photo Credit: Uchembere Wangwiro Program.
Results-Based Financing for Maternal Neonatal Health (RBF4MNH)

Results-based financing (RBF) schemes have developed rapidly across sub-Saharan Africa, but a substantial knowledge gap about how RBF interventions impact quality of care of essential obstetric and newborn care (EONC) remains. Researchers from the University of Heidelberg and their partners at the College of Medicine Malawi aimed to reduce the knowledge gap by providing a scientific assessment of the expected and unexpected impacts of implementation of an RBF program in Malawi on EONC care quality. This study was co-funded by TRAction and the Norwegian Agency for Development Cooperation.

Scaling-Up Management for Results in Guatemala

Photo of Child outside home in Guatemala, Photoshare
Scaling-Up Management for Results Strategy

The Management for Results Strategy in Guatemala aims to efficiently allocate and manage human, financial, and technological resources toward the achievement of human development goals. This includes the articulation of policies, strategies, resources and processes to improve decision-making, transparency, accountability, and interactions between the Ministry of Public Health and Social Welfare (MSPAS) and the Ministry of Finance. Through the implementation of the Management for Results Strategy, Guatemala aims to honor three major pacts defined by the current Government: the Zero Hunger Pact; the Peace, Security and Justice Pact; and the Fiscal Reform and Competitiveness Pact. In particular, this is an opportunity for the MSPAS to improve the health service provision, in alignment with the Zero Hunger Pact, which aims to reduce maternal mortality and chronic malnutrition among children under five.

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