Send to friendWith half a million of its 21 million citizens living with HIV, Cote D’Ivoire ranks as “one of the countries most affected…in West Africa,” according to the US Agency for International Development (USAID). Active in the country since 2004, the Elizabeth Glazer Pediatric AIDS Foundation decided in 2006 to use performance-based financing (PBF) at four of the private clinics it supports in the country. (Legal restrictions prevented public clinics from receiving incentive payments.) Though initially delayed by a civil war that ended in 2007, by late 2010 the PBF system covered 32 of the foundation’s 139 HIV sites in Cote d’Ivoire, and efforts are underway to extend it further.
Preventing mother-to-child transmission (MTCT) of the HIV virus is one of the PBF program’s top priorities, because Cote d’Ivoire’s women are “disproportionately affected” by the epidemic, according to USAID, with an infection rate of six percent among those aged 15 to 45, as opposed to less than three percent for comparable men. Young women between the ages of 20 and 24 are especially vulnerable, being “15 times more likely to be HIV positive” than comparable men. The program also focuses on providing voluntary counseling and testing, and treating HIV in both adults and children.
To measure performance in each of the priority areas, the PBF program uses a set of indicators that includes such services as MCTC prevention steps at delivery, providing postpartum care, testing of the sexual partners and children of HIV-positive individuals, referring patients to needed services, and providing HIV-status screening and appropriate treatment for both adults and children.
A cooperative agreement between the foundation and each site specifies targets for how many of each indicator service the clinic is expected to deliver each month. All sites use the same set of indicators, but with specific targets tailored to each site’s circumstances and capacities. The foundation agrees to pay a pre-determined amount for each time an indicator service is delivered, plus a premium of about 10% for care delivered to children in order to encourage facilities to build up their child services.
As a contract begins, the site receives an advance of 10% - 25% of its projected total payments to cover startup costs and initial cash flow. Then, it invoices every month for the specific number of indicator services it has rendered. Validation procedures, as well as quarterly progress reports, aim to assure accuracy. The foundation pays the clinic the invoiced amount for each indicator whose monthly target has been met. Sites receive payment only for services they actually provide, with no guarantee of a minimum payment.
When a contract ends, the site receives bonuses of 25% of the payments for each indicator whose target was surpassed in every month of the contract period. The amount reflects the actual number of services delivered in excess of the target, up to an agreed-upon maximum. Sites must also indicate in advance how they plan to spend the bonuses, the acceptable uses being either improving equipment and infrastructure, staff training or else dividing the bonus equitably among the staff.
Little rigorous research has examined PBF’s effects on HIV services, the foundation notes, but its own surveys of staff at its PBF sites show very favorable reactions. “Improving organizational collaboration, cultivating better working conditions, and positively influencing staff morale and motivation” are some of the effects staff ascribe to the approach, the foundation reports. Staff also see PBF as responsible for better “development and integration of activities…, improved data collection, and improved overall clinic performance.” Along with the additional funding that PBF incentives has made available, staff say, these results have “enhanced the ability of health-care sites to expand HIV testing, prevention, care, and treatment services, and reach more patients,” especially by bringing services to patients through mobile outreach efforts.
They do identify challenges and obstacles - specifically the need for more training in handling reporting requirements and data systems, and in communicating clearly about targets and expectations. Importantly, however, they think that PBF has “increased patient loyalty and demand for services”—which may mean that more people are getting and sticking with their treatment.