Structuring Health Care Systems to Promote Accountability and Quality
Background and Strategy
PHR conducted work on structuring incentives to improve the quality and efficiency of care, including studies of health worker motivation and provider payment, as well as interventions in these areas. In certain respects, PHRplus work has grown out of this prior body of work. PHRplus conducts analyses and designs interventions that address how system level interventions (as opposed to facility level ones) can promote quality of care. PHRplus works on two principal types of interventions aimed at improving quality of care, namely (i) regulation and accreditation and (ii) performance-based contracting. While governance structures have many purposes, a key one is to assure responsiveness of services to community needs, an important dimension of quality. As with most PHRplus themes, work on accountability and quality encompasses knowledge building, technical assistance to design and implement interventions, and dissemination of key lessons learned.
- Regulation and accreditation: PHRplus country activities in Albania, Honduras, and Egypt have elements that focus on regulation and accreditation. In Honduras, PHRplus has been providing support to the government to develop a comprehensive regulatory framework; PHRplus will help get this framework approved and implement facility licensing procedures in at least one region. In Albania and Egypt, work on quality is part of a larger reform strategy being piloted by the Project. In Albania, the Project is helping to formulate strategy for the implementation of a quality assurance program, produce an accreditation strategy, and draft clinical practice guidelines. In Egypt, the Project is supporting a process to help establish a hospital accreditation system. PHRplus also plans to conduct research on government's stewardship role with respect to regulation and incentive setting. While many governments have regulatory statutes and incentive systems, these commonly function poorly. PHRplus will develop a concept paper reviewing the binding constraints on effective regulatory implementation and conduct case studies in two to four countries.
- Performance-based contracting: many governments have been attracted to the concept of moving from integrated health care systems to contracting providers based upon performance. It is believed that improvements in quality and efficiency can be gained through setting standards and making payment to providers contingent upon meeting these standards. In El Salvador and Jordan, PHRplus is assisting the government to put such plans into effect. In El Salvador, the government plans to contract with decentralized management units called SIBASIs, and in Jordan the MOH will contract private providers to deliver reproductive health care services. PHRplus is also providing technical assistance in this area to mutual health organizations in Ghana: the Project is producing a manual and train MHO managers with it to help them address quality issues when they contract providers (see section 1). Building upon this experience, PHRplus is developing a primer to advise governments on how to monitor and evaluate performance-based contracting initiatives.
- Accountability and governance: many health systems strengthening strategies include some element aimed at strengthening accountability, particularly accountability of service providers to users and the population more broadly. PHRplus has completed a conceptual framework paper that analyzes different types of accountability and various approaches to strengthening accountability.