Understanding efficiency and the effect of pay-for-performance across health facilities in Tanzania
Open Access
- 1 May 2020
- journal article
- research article
- Published by BMJ in BMJ Global Health
- Vol. 5 (5), e002326
- https://doi.org/10.1136/bmjgh-2020-002326
Abstract
Background Ensuring efficient use and allocation of limited resources is crucial to achieving the UHC goal. Performance-based financing that provides financial incentives for health providers reaching predefined targets would be expected to enhance technical efficiency across facilities by promoting an output-oriented payment system. However, there is no study which has systematically assessed efficiency scores across facilities before and after the introduction of pay-for-performance (P4P). This paper seeks to fill this knowledge gap. Methods We used data of P4P evaluation related to healthcare inputs (staff, equipment, medicines) and outputs (outpatient consultations and institutional deliveries) from 75 health facilities implementing P4P in Pwani region, and 75 from comparison districts in Tanzania. We measured technical efficiency using Data Envelopment Analysis and obtained efficiency scores across facilities before and after P4P scheme. We analysed which factors influence technical efficiency by regressing the efficiency scores over a number of contextual factors. We also tested the impact of P4P on efficiency through a difference-in-differences regression analysis. Results The overall technical efficiency scores ranged between 0.40 and 0.65 for hospitals and health centres, and around 0.20 for dispensaries. Only 21% of hospitals and health centres were efficient when outpatient consultations and deliveries were considered as output, and <3% out of all facilities were efficient when outpatient consultations only were considered as outputs. Higher efficiency scores were significantly associated with the level of care (hospital and health centre) and wealthier catchment populations. Despite no evidence of P4P effect on efficiency on average, P4P might have improved efficiency marginally among public facilities. Conclusion Most facilities were not operating at their full capacity indicating potential for improving resource usage. A better understanding of the production process at the facility level and of how different healthcare financing reforms affects efficiency is needed. Effective reforms should improve inputs, outputs but also efficiency.Keywords
This publication has 72 references indexed in Scilit:
- Performance-based financing as a health system reform: mapping the key dimensions for monitoring and evaluationBMC Health Services Research, 2013
- Protocol for the evaluation of a pay for performance programme in Pwani region in Tanzania: A controlled before and after studyImplementation Science, 2013
- Paying for performance to improve the delivery of health interventions in low- and middle-income countriesCochrane Database of Systematic Reviews, 2012
- Efficiency of primary care in rural Burkina Faso. A two-stage DEA analysisHealth Economics Review, 2011
- Performance-based financing: just a donor fad or a catalyst towards comprehensive health-care reform?Bulletin of the World Health Organization, 2011
- Bypassing primary care facilities for childbirth: a population-based study in rural TanzaniaHealth Policy and Planning, 2009
- Using data envelopment analysis to measure the extent of technical efficiency of public health centres in GhanaBMC International Health and Human Rights, 2008
- Primary health care: making Alma-Ata a realityThe Lancet, 2008
- Can family planning outreach bridge the urban-rural divide in Zambia?BMC Health Services Research, 2007
- Investigating health system performance: An application of data envelopment analysis to Zambian hospitalsBMC Health Services Research, 2007