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      In Tanzania, The Many Costs Of Pay-For-Performance Leave Open To Debate Whether The Strategy Is Cost-Effective

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          Abstract

          Pay-for-performance programs in health care are widespread in low- and middle-income countries. However, there are no studies of these programs' costs or cost-effectiveness. We conducted a cost-effectiveness analysis of a pay-for-performance pilot program in Tanzania and modeled costs of its national expansion. We reviewed project accounts and reports, interviewed key stakeholders, and derived outcomes from a controlled before-and-after study. In 2012 US dollars, the financial cost of the pay-for-performance pilot was $1.2 million, and the economic cost was $2.3 million. The incremental cost per additional facility-based birth ranged from $540 to $907 in the pilot and from $94 to $261 for a national program. In a low-income setting, the costs of managing the program and generating and verifying performance data were substantial. Pay-for-performance programs can stimulate the generation and use of health information by health workers and managers for strategic planning purposes, but the time involved could divert attention from service delivery. Pay-for-performance programs may become more cost-effective when integrated into routine systems over time.

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          Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

          Nicholas J. Kassebaum, Amelia Bertozzi-Villa, Megan S Coggeshall … (2014)
          The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery. We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values. 292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland. Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa. Bill & Melinda Gates Foundation. Copyright © 2014 Elsevier Ltd. All rights reserved.
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            Child survival gains in Tanzania: analysis of data from demographic and health surveys.

            Honorati Masanja, Don de Savigny, Paul Smithson … (2008)
            A recent national survey in Tanzania reported that mortality in children younger than 5 years dropped by 24% over the 5 years between 2000 and 2004. We aimed to investigate yearly changes to identify what might have contributed to this reduction and to investigate the prospects for meeting the Millennium Development Goal for child survival (MDG 4). We analysed data from the four demographic and health surveys done in Tanzania since 1990 to generate estimates of mortality in children younger than 5 years for every 1-year period before each survey back to 1990. We estimated trends in mortality between 1990 and 2004 by fitting Lowess regression, and forecasted trends in mortality in 2005 to 2015. We aimed to investigate contextual factors, whether part of Tanzania's health system or not, that could have affected child mortality. Disaggregated estimates of mortality showed a sharp acceleration in the reduction in mortality in children younger than 5 years in Tanzania between 2000 and 2004. In 1990, the point estimate of mortality was 141.5 (95% CI 141.5-141.5) deaths per 1000 livebirths. This was reduced by 40%, to reach a point estimate of 83.2 (95% CI 70.1-96.3) deaths per 1000 livebirths in 2004. The change in absolute risk was 58.4 (95% CI 32.7-83.8; p<0.0001). Between 1999 and 2004 we noted important improvements in Tanzania's health system, including doubled public expenditure on health; decentralisation and sector-wide basket funding; and increased coverage of key child-survival interventions, such as integrated management of childhood illness, insecticide-treated nets, vitamin A supplementation, immunisation, and exclusive breastfeeding. Other determinants of child survival that are not related to the health system did not change between 1999 and 2004, except for a slow increase in the HIV/AIDS burden. Tanzania could attain MDG 4 if this trend of improved child survival were to be sustained. Investment in health systems and scaling up interventions can produce rapid gains in child survival.
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              The national free delivery and caesarean policy in Senegal: evaluating process and outcomes.

              T Dieng, Isabelle Moreira-Burgos, Sophie Witter … (2010)
              This article presents the results of an evaluation of the free delivery and caesarean policy (FDCP) in Senegal. The policy was introduced into five poor regions in 2005 and in 2006 was extended at regional hospital level to all regions apart from the capital (Dakar). The evaluation was carried out in 2006-7. There were four research components, all focused on selected facilities and districts within the five FDCP regions: a financial analysis of expenditure on the policy and wider health financing in the five regions and nationally; 54 key informant interviews from national down to facility level; 10 focus group discussions and 8 in-depth interviews; and analysis based on clinical record extraction of 761 major obstetric interventions. The evaluation found significant implementation difficulties, especially related to the allocation of funds and kits and the adequacy of their contents. Despite that, significant increases in utilization in normal deliveries (from 40% to 44% of expected deliveries in FDCP areas over 2004-5) and in caesarean rates (rising from 4.2% to 5.6% in FDCP areas) were recorded. National data suggested that these trends were not found in non-FDCP regions. Using the evaluation data, the cost per additional caesarean under the policy was US$467 and the cost per additional supervised normal delivery was US$21. The article concludes that, in order to achieve its full potential, the FDCP requires improved systems for planning and allocating resources, and new channels to reimburse lower level facilities. It is also important that all complicated deliveries (not just caesareans) are included in the package. In the case of Senegal, a complementary strategy of investment in facilities, transportation and staffing is required to bring greater geographical access and upgrade services. These findings are likely to be relevant to other countries currently experimenting with similar approaches to reducing financial barriers to skilled attendance at delivery.
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                Author and article information

                Journal
                Title: Health Affairs
                Abbreviated Title: Health Affairs
                Publisher: Health Affairs (Project Hope)
                ISSN (Print): 0278-2715
                ISSN (Electronic): 1544-5208
                Publication date Created: March 2015
                Publication date (Print): March 2015
                Volume: 34
                Issue: 3
                Pages: 406-414
                Affiliations
                [1 ] Josephine Borghi ( ) is a senior lecturer in the Department of Global Health and Development, London School of Hygiene and Tropical Medicine.
                [2 ] Richard Little is a consultant health economist in Cambridge, England.
                [3 ] Peter Binyaruka is a research scientist at the Ifakara Health Institute.
                [4 ] Edith Patouillard is a senior scientific collaborator in the Epidemiology and Public Health Department, Health Intervention Unit, Swiss Tropical and Public Health Institute, in Basel; the University of Basel; and the World Health Organization Global Malaria Programme, in Geneva, Switzerland.
                [5 ] August Kuwawenaruwa is a research scientist at the Ifakara Health Institute, in Dar es Salaam, Tanzania.
                Article
                DOI: 10.1377/hlthaff.2014.0608
                PubMed ID: 25732490
                SO-VID: bfa290f5-3cb7-4502-8ac4-91bba27f5d8c
                Copyright © © 2015
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