Performance-based payment to providers: A new twist with institutional target to improve facility performance

Background: Effective human resource intervention is warranted to achieve the MDG target 5 in Bangladesh. Absenteeism is rampant in public health facilities with almost 40% doctors remaining absent. The demand-side-financing (DSF) model narrowly focuses on increasing pregnancy related services by offering payment to the providers on case to case basis without addressing the institutional building and quality of care. In this context, the Government has initiated a new model with incentives for improving institutional obstetric care performance.

Methods: Based on literature reviews and consultation with the stakeholders, an institutional pay-for-performance (P4P) model has been developed, which allows incentives for individual providers for obtaining the institution's quantitative and qualitative targets. It employs Nash equilibrium, where all of the players' expectations are fulfilled and their chosen strategies are optimal towards achieving the institutional targets. Two levels of incentives tied with the basic salary are the incentives for achieving the targets.

Results: Three facilities achieved second level and eight facilities achieved first level targets while one facility failed meeting any target. Number of cesarean section in three emergency obstetric facilities increased by 20% to 194%; and normal deliveries at 11 facilities increased by 20% to 265%. The model motivated facility management and; facility-based quality assurance teams of about 600 members to make the emergency room, labor room, obstetric ward, children's ward and Operation Theater functional. Triggered with new ideas, motivated managers and providers went beyond borders to make the services efficient and functional by introducing use of partographs, establishing antenatal and breast-feeding corners, ensuring privacy and confidentiality and taking infection prevention measures.

Conclusions: Instead of piecemeal-basis improvement of provider's quantitative services of the DSF model, the P4P model is superior for in-built facility strengthening and employing standardization in quantitative and qualitative achievements. This model can also be applied in other developing county settings.