antenatal care

The subsection revisits the same indicators of overuse discussed in chapter 4—too early initiation of preventive malaria treatment and too early provision of the tetanus vaccine. These measures are defined as (1) initiating preventive malaria treatment and (2) providing the tetanus vaccine in the first trimester, while the WHO guidelines state that it should only be provided in the second trimester or later. Further, the too-early provision of preventive malaria treatment is not only an instance of unnecessary care that is an inefficient use of resources, but also harmful to the growing fetus (Peters et al. 2007; Hernandes-Diaz et al. 2000).

As discussed in detail in chapters 5 and 6, the Nigerian and Cameroonian PBF pilots included business-as-usual as well as a direct facility financing (DFF) arm for comparison. In the latter, facilities were provided enhanced financing and autonomy over the expenditure of the additional budget but were not allowed to use it for staff remuneration. Figure 7.5 presents the evidence from Cameroon and Nigeria on the impacts of PBF on overuse compared with the business-as-usual and DFF arms. Relative to businessas-usual, in Nigeria, the suggestions that the PBF intervention may have led to increases in the overuse of malaria treatment and tetanus shot provision were imprecisely estimated. Tetanus shots were explicitly incentivized

Figure 7.5 Assessing the impact of PBF on indicators of overuse in antenatal care

a. (Business-as-usual or DFF) vs. PBF b. DFF vs. PBF

Tetanus vaccine

Preventative malaria treatment

–0.4 –0.2 0 0.2 0.4 –0.4 –0.2

PBF treatment effect

Cameroon Nigeria 0 0.2 0.4

Sources: World Bank, based on Khanna et al. 2021 and de Walque et al. 2021.

Note: “Whiskers” represent 95% confidence intervals. SE clustered at the treatment level. DFF = direct facility financing; PBF = performance-based financing; SE = standard errors.

under the payment scheme (Khanna et al. 2021). In Cameroon, the intervention also purchased the provision of tetanus vaccines in pregnancy. Relative to both business-as-usual and DFF, PBF does not appear to increase the overuse of tetanus shots, although again neither effect is precisely estimated. Relative to DFF in Nigeria, PBF led to smaller and again insignificant impacts on malaria treatment as well as tetanus vaccination.

Quality measurement to inform incentives at scale The chapter has argued that financial incentives that reward quantity indiscriminately can actually lower the quality of care. This implies that welldesigned incentive schemes must appropriately measure and reward quality rather than quantity. Chapter 3 provides an overview of the various ways of measuring quality of care used in research; when adapting such measures to implement performance-based incentives, policy makers must carefully consider two things: first, what aspect of quality and effort to reward and how; and second, what the potential advantages and drawbacks of the various measurement methods are in the context of implementing incentives. The optimal at-scale design of performance-based incentives in health care remains an important question for future research, but some lessons can be drawn from existing studies.

A series of seminal contributions in economics considers the problem of incentivizing performance by an “agent”—here, the health worker—in environments where effort is hard to assess and the agent performs multiple complex tasks (Baker, Gibbons, and Murphy 1994; Holmström 1979; Holmström and Milgrom 1991, 1994). Some of the lessons are useful for thinking about incentives in health care. The first insight is that it is usually best to reward the ultimate outcome of interest, such as the population’s overall health and happiness, especially when it is difficult to observe and evaluate the “inputs” into this output—such as the quality of the individual provider-patient interaction. However, when the output is only very indirectly related to the agent’s actions, an outcome-based incentive effectively holds the agent responsible for bad outcomes that they have no power to prevent (say, the outbreak of a viral disease), and this risk puts limits on making pay dependent on outcomes. In this setting, it is best to use all the information that contributes to a more complete picture of the agent’s actions, including directly observing them (for example, via standardized patient visits). Subjective assessments, such as patient satisfaction surveys or supervisor evaluations, may be preferred

to objective, quantitative metrics when some aspects of performance are much harder to measure than others, such as pain levels or care for chronic illness.

Finally, when important aspects of care cannot be measured, financial incentives can be counterproductive because they divert the health worker’s attention away from the unmeasured quality aspects to the measured ones. A well-calibrated system of financial incentives therefore likely combines a variety of subjective as well as objective quality measures, such as patient interviews, population surveys, and standardized patient visits, and may provide a variety of incentive structures for different types or specialties of providers, depending on the tasks these groups are expected to perform. In addition, performance metrics should be adjustable over time and account for overuse as an aspect of quality. Each specific implementation should be accompanied by research that assesses long-run health outcomes and may trigger a readjustment.

An important consideration for the practical implementation will also be whether a specific measurement approach can assess quality of care in a reliable and unbiased manner. As an example, when using direct clinical observation for research purposes, researchers find that physicians seem to return quickly to their usual conduct and practice (Leonard and Masatu 2010). However, this is likely not true in situations where the physician knows that she or he is being evaluated with the purpose of determining performance-based pay. Thus, basing the incentive on clinical observation will reward the provider’s knowledge and skill but not their day-to-day effort.

Another example is the use of patient satisfaction surveys to evaluate providers in the context of overuse. In many contexts, patient surveys can be very informative, for instance, about aspects of quality such as the provider’s general conduct and approachability or the time spent with the patient as well as the price of care. However, in the malaria case study, patient satisfaction was overall lower when patients received unnecessary malaria treatment less often (Lopez, Sautmann, and Schaner 2022a). More generally, patients may demand overtreatment and therefore paradoxically low quality of care. It is necessary to validate carefully whether a given indicator truly rewards the desired behavior by the physician. An important aspect of any performance-based incentive scheme should thus be the cost of providing a given level of care or the efficiency of care. Performancelinked payments may otherwise lead to misaligned incentives that generate rapid cost increases.