Photo credit: World Bank/Nick van Praag
The Kyrgyz Republic benefits from universal basic health care, leading to high levels of health service coverage and utilization. For instance, 99 percent of women delivered with a skilled birth attendant, and almost 84 percent of women attended four or more antenatal care visits (DHS, 2012). Nevertheless, its maternal and child mortality rates are amongst the highest in Central Asia, with 76 maternal deaths per 100,000 live births (World Bank, 2015) and 31 child deaths per 1,000 live births (DHS, 2012). These relatively high mortality rates, coupled with high levels of coverage of MH services, points to complex systemic challenges notably poor quality of care.
RBF AT A GLANCE
The Kyrgyz Health Results-Based Financing project comprises of two interlinked pilot interventions. The first pilot intervention consists of a randomized controlled trial implemented to test the feasibility and impact of a pay-for-quality performance-based financing (PBF) scheme at rayon (district) hospitals. The first pilot includes three arms, to which all district hospitals were randomly assigned: arm 1 – 22 district hospitals receiving enhanced supervision to support quality improvement linked to performance-based payment based on hospital quality scores; arm 2 – 21 rayon-level hospitals receiving enhanced supervision to support quality improvement only and no performance-based payments; and arm 3 – 21 rayon-level hospitals receiving no interventions. Hospital quality is measured using a Balanced Score Card (BSC) approach. The second intervention will pilot PBF at the primary care level, providing PBF payments based on the quality and on the quantity of services delivered in four rayons.
The RBF verification function involves quarterly peer verifications of quality, using a Balanced Scorecard to measure structural improvements, clinical processes and client satisfaction. It also includes semi-annual counter-verifications conducted randomly to ascertain the accuracy of results.
Status and achievements
In December 2016, data indicated an increase in quality scores from 12 percent at baseline level (2014) to 80 percent in the treatment group; and from 9 to 63 percent in the comparison group (i.e. with quarterly monitoring but without PBF payments). Counter-verifications conducted in March 2015, September 2015 and March 2016 in 10 randomly selected hospitals (i.e. 5 in each of the abovementioned arms) showed a score difference within the acceptable threshold of 10 percent.
Today, improvements in the quality of care have started to stabilize: while hospitals have done remarkably well in improving the structural aspects of quality, clinical processes and content of care are somewhat lagging behind. This situation signaled the need to invest considerably in building the knowledge and skills of frontline workers, and led to including a knowledge component in the Balanced Scorecard in August 2015. To date, the project has introduced: (i) observation of neonatal resuscitation skills using NeoNatalie anatomical models; (ii) skills to manage emergency obstetric conditions such as postpartum hemorrhage, eclampsia and shock using MamaNatalie birthing simulator and first aid kits; (iii) simulation of WHO Surgical Safety Checklist aimed at reducing preventable complications of surgeries and medical errors. The project plans to use clinical vignettes to enhance provider knowledge and adherence to evidence-based clinical protocols.
The PBF model targeting primary health care facilities was developed in close collaboration with partners and stakeholders. It will be implemented jointly by the World Bank, a Swiss-funded project, USAID Defeat TB Project, and the World Health Organization.
- Political stability is essential to ensure successful project implementation.
- Integrating qualitative and quantitative methods at baseline and midterm stages of the impact evaluation can help inform the impact evaluation and better shape the program.
EVALUATION AT A GLANCE
Baseline survey data on the quality of care were collected in 64 rayon hospitals in 2012-2013. Survey results were presented to all stakeholders in December 2015. A mid-term review of the project was conducted in October-November 2016 and a midline impact evaluation survey is planned for March-April 2017.
* A request from the Ministry of Finance to restructure the project and extend the closing date until December 2018 is being considered.