Quality of Care in Performance-Based Financing: How It Is Incorporated in 32 Programs Across 28 Countries

Objective: To describe how quality of care is incorporated into performance-based financing (PBF) programs, what quality indicators are being used, and how these indicators are measured and verified.

Methods: An exploratory scoping methodology was used to characterize the full range of quality components in 32 PBF programs, initiated between 2008 and 2015 in 28 low- and middle-income countries, totaling 68 quality tools and 8,490 quality indicators. The programs were identified through a review of the peer-reviewed and gray literature as well as through expert consultation with key donor representatives.

Findings: Most of the PBF programs were implemented in sub-Saharan Africa and most were funded primarily by the World Bank. On average, PBF quality tools contained 125 indicators predominately assessing maternal, newborn, and child health and facility management and infrastructure. Indicators were primarily measured via checklists (78%, or 6,656 of 8,490 indicators), which largely (over 90%) measured structural aspects of quality, such as equipment, beds, and infrastructure. Of the most common indicators across checklists, 74% measured structural aspects and 24% measured processes of clinical care. The quality portion of the payment formulas were in the form of bonuses (59%), penalties (27%), or both (hybrid) (14%). The median percentage (of a performance payment) allocated to health facilities was 60%, ranging from 10% to 100%, while the median percentage allocated to health care providers was 55%, ranging from 20% to 80%. Nearly all of the programs included in the analysis (91%, n=29) verified quality scores quarterly (every 3 months), typically by regional government teams.

Conclusion: PBF is a potentially appealing instrument to address shortfalls in quality of care by linking verified performance measurement with strategic incentives and could ultimately help meet policy priorities at the country and global levels, including the ambitious Sustainable Development Goals. The substantial variation and complexity in how PBF programs incorporate quality of care considerations suggests a need to further examine whether differences in design are associated with differential program impacts.