The effectiveness of pay-for-performance contracts with non-governmental organizations in Afghanistan – results of a controlled interrupted time series analysis
Abstract Background In many contexts, including fragile settings like Afghanistan, the coverage of basic health services is low. To address these challenges there has been considerable interest in working with NGOs and examining the effect of financial incentives on service providers. The Government...
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| Format: | Article |
| Language: | English |
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BMC
2023-02-01
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| Series: | BMC Health Services Research |
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| Online Access: | https://doi.org/10.1186/s12913-023-09099-y |
| _version_ | 1811165987124281344 |
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| author | Diwa Samad Bashir Hamid Ghulam Dastagir Sayed Yueming Liu Wu Zeng Alexander K. Rowe Benjamin Loevinsohn |
| author_facet | Diwa Samad Bashir Hamid Ghulam Dastagir Sayed Yueming Liu Wu Zeng Alexander K. Rowe Benjamin Loevinsohn |
| author_sort | Diwa Samad |
| collection | DOAJ |
| description | Abstract Background In many contexts, including fragile settings like Afghanistan, the coverage of basic health services is low. To address these challenges there has been considerable interest in working with NGOs and examining the effect of financial incentives on service providers. The Government of Afghanistan has used contracting with NGOs for more than 15 years and in 2019 introduced pay-for-performance (P4P) into the contracts. This study examines the impact of P4P on health service delivery in Afghanistan. Methods We conducted an interrupted time series (ITS) analysis with a non-randomized comparison group that employed segmented regression models and used independently verified health management information system (HMIS) data from 2015 to 2021. We compared 31 provinces with P4P contracts to 3 provinces where the Ministry of Public Health (MOPH) continued to deliver services without P4P. We used data from annual health facility surveys to assess the quality of care. Findings Independent verification of the HMIS data found that consistency and accuracy was greater than 90% in the contracted provinces. The introduction of P4P increased the 10 P4P-compensated service delivery outcomes by a median of 22.1 percentage points (range 10.2 to 43.8) for the two-arm analysis and 19.9 percentage points (range: - 8.3 to 56.1) for the one-arm analysis. There was a small decrease in quality of care initially, but it was short-lived. We found few other unintended consequences. Interpretation P4P contracts with NGOs led to a substantial improvement in service delivery at lower cost despite a very difficult security situation. The promising results from this large-scale experience warrant more extensive application of P4P contracts in other fragile settings or wherever coverage remains low. |
| first_indexed | 2024-04-10T15:45:05Z |
| format | Article |
| id | doaj.art-2c74d00f0a6e4398a19b5062c04d4c44 |
| institution | Directory Open Access Journal |
| issn | 1472-6963 |
| language | English |
| last_indexed | 2024-04-10T15:45:05Z |
| publishDate | 2023-02-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Health Services Research |
| spelling | doaj.art-2c74d00f0a6e4398a19b5062c04d4c442023-02-12T12:07:44ZengBMCBMC Health Services Research1472-69632023-02-0123111210.1186/s12913-023-09099-yThe effectiveness of pay-for-performance contracts with non-governmental organizations in Afghanistan – results of a controlled interrupted time series analysisDiwa Samad0Bashir Hamid1Ghulam Dastagir Sayed2Yueming Liu3Wu Zeng4Alexander K. Rowe5Benjamin Loevinsohn6The Global Fund to Fight AIDS, Tuberculosis and MalariaThe Global Fund to Fight AIDS, Tuberculosis and MalariaThe World BankFeinberg School of Medicine, Northwestern University- United StatesDepartment of Global Health, Georgetown University- United StatesThe Global Fund to Fight AIDS, Tuberculosis and MalariaGavi, The Vaccine AllianceAbstract Background In many contexts, including fragile settings like Afghanistan, the coverage of basic health services is low. To address these challenges there has been considerable interest in working with NGOs and examining the effect of financial incentives on service providers. The Government of Afghanistan has used contracting with NGOs for more than 15 years and in 2019 introduced pay-for-performance (P4P) into the contracts. This study examines the impact of P4P on health service delivery in Afghanistan. Methods We conducted an interrupted time series (ITS) analysis with a non-randomized comparison group that employed segmented regression models and used independently verified health management information system (HMIS) data from 2015 to 2021. We compared 31 provinces with P4P contracts to 3 provinces where the Ministry of Public Health (MOPH) continued to deliver services without P4P. We used data from annual health facility surveys to assess the quality of care. Findings Independent verification of the HMIS data found that consistency and accuracy was greater than 90% in the contracted provinces. The introduction of P4P increased the 10 P4P-compensated service delivery outcomes by a median of 22.1 percentage points (range 10.2 to 43.8) for the two-arm analysis and 19.9 percentage points (range: - 8.3 to 56.1) for the one-arm analysis. There was a small decrease in quality of care initially, but it was short-lived. We found few other unintended consequences. Interpretation P4P contracts with NGOs led to a substantial improvement in service delivery at lower cost despite a very difficult security situation. The promising results from this large-scale experience warrant more extensive application of P4P contracts in other fragile settings or wherever coverage remains low.https://doi.org/10.1186/s12913-023-09099-yNGOsContractingHealthAfghanistanPay-for-performanceResults-based financing |
| spellingShingle | Diwa Samad Bashir Hamid Ghulam Dastagir Sayed Yueming Liu Wu Zeng Alexander K. Rowe Benjamin Loevinsohn The effectiveness of pay-for-performance contracts with non-governmental organizations in Afghanistan – results of a controlled interrupted time series analysis BMC Health Services Research NGOs Contracting Health Afghanistan Pay-for-performance Results-based financing |
| title | The effectiveness of pay-for-performance contracts with non-governmental organizations in Afghanistan – results of a controlled interrupted time series analysis |
| title_full | The effectiveness of pay-for-performance contracts with non-governmental organizations in Afghanistan – results of a controlled interrupted time series analysis |
| title_fullStr | The effectiveness of pay-for-performance contracts with non-governmental organizations in Afghanistan – results of a controlled interrupted time series analysis |
| title_full_unstemmed | The effectiveness of pay-for-performance contracts with non-governmental organizations in Afghanistan – results of a controlled interrupted time series analysis |
| title_short | The effectiveness of pay-for-performance contracts with non-governmental organizations in Afghanistan – results of a controlled interrupted time series analysis |
| title_sort | effectiveness of pay for performance contracts with non governmental organizations in afghanistan results of a controlled interrupted time series analysis |
| topic | NGOs Contracting Health Afghanistan Pay-for-performance Results-based financing |
| url | https://doi.org/10.1186/s12913-023-09099-y |
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