Academic journal article Journal of Health Population and Nutrition

Impact of a Service Provider Incentive Payment Scheme on Quality of Reproductive and Child-Health Services in Egypt

Academic journal article Journal of Health Population and Nutrition

Impact of a Service Provider Incentive Payment Scheme on Quality of Reproductive and Child-Health Services in Egypt

Article excerpt


There is an extensive literature on different types of payment methods for healthcare providers and the effects of incentives on organizations and individuals in the healthcare system (1,2). The evidence on incentive payments based upon specific performance criteria is generally mixed, though suggestive of several positive effects on the quality of care and, cost-containment measures. However, the findings in many settings are difficult to interpret as the introduction of payment reforms is often accompanied with other changes in the service-delivery. setting that affect the quality of care.

Incentives are known to elicit complex responses from physicians, inducing changes in the number of hours worked for the number of beneficiaries seen per hour, the location of their work, and the type of service provided to a patient (3,4). The introduction of incentive payments linked to the productivity of the service provider can lead to over-valuing certain procedures or services, producing inefficiencies and unnecessary care. For example, payments made to clients, medical personnel, and outreach workers who motivate and refer clients for family planning have been a concern for national family-planning programmes (5). In general, experience with the incentive payment schemes shows that they can lead to multiple impacts on behaviours of service provider--both intended and unintended--and must be carefully monitored (6-8).

There are also other risks in the use of incentive payments. For example, performance-based incentive payment schemes increase the level of administrative costs because these require data on the number and type of services provided and have been criticized for these hidden costs (9,10). Thus, the success of an incentive payment system will depend upon the efficient operations of the financial and management systems that underpin the payments (11) and careful selection of the performance measures.

Despite these other well-known difficulties and risks, payments of salary (either in part or whole) that are linked to performance measures are attractive policy options as a means to improving the quality of service and gaining efficiencies.

Setting of study

Beginning in the middle of the 1990s, the Government of Egypt began to openly grapple with solutions to pressing problems that the piecemeal approach to reform used previously had failed to resolve. There were significant equity problems in access to services, by both income and geographical groupings, and public spending on health was regressive (12). The organization of the health sector and its management was burdened with a cumbersome mix of centralized and decentralized functions. Financing of the health sector was fragmented and uncoordinated, prohibiting effective risk-pooling and encouraging predatory behaviours among service providers. The delivery system was characterized by substantial excess capacity and under-use of sub-standard quality facilities. There were both surpluses and imbalances of medical personnel, with an over-supply of specialists, under-supply of primary care physicians, and absolute shortage of nurses.

The 1997 Health Sector Reform Strategy Paper responded to these challenges by setting a longterm vision of universal coverage with basic health services for all citizens (13). The pilot phase (1998-2004) of the Egyptian Health Sector Reform Program (HSRP) focused on primary healthcare in a Family Health Project that modelled several basic reform principles, including creating a Family Health Fund (a social insurance scheme) to reduce out-of-pocket expenditure for a Basic Benefit Package that includes reproductive health services (family planning, maternal and newborn care) (14).

At the close of the HSRP pilot phase, several important initiatives had been introduced (e.g. basic benefit package) while other reforms had not yet been evaluated. Among the later was a set of reforms targeting payments to healthcare providers that were developed in part a response to long overdue increases in salaries in the public sector and also as a means for improving the quality of care. …

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