Strengthening Financial Incentives to Improve the Quality of Primary Care in Cote d’Ivoire

Abstract

As low- and middle-income countries move towards universal health coverage, limited financing and low quality of care continue to be a significant problem. Policymakers frequently use financial incentives to improve quality of care, but their effectiveness varies across contexts, given the complex adaptive nature of health systems. This project studies how financial incentives can be leveraged to improve the quality of primary care in Cote d’Ivoire, a lower-middle income country with a weak health system. A framework which identified five pathways through which financial incentives can influence quality of care was developed to study these links. Based on this framework, semi-structured interviews were conducted with 82 policymakers and health workers, and routine data from the national pilot of a performance-based financing (PBF) program was analyzed. The analysis found that fragmentation in financing and the lack of a standardized vision for high-quality care constrained the potential of financial incentives to improve quality of care, and financial incentives in return did not improve the quality of care in an integrated manner. In contracted facilities, PBF was found to have increased a quality index (including facility-wide inputs, disease-specific inputs, and management) by 40-60% depending on phase and facility type, but had limited success in improving process and outcome measures of quality, as well as involving the community and improving patient satisfaction. Informed by these improvements and shortcomings, this project recommends transformative change for the Ivorian health financing system to maximize quality of care through formalizing innovation and establishing a learning health system; agreeing on a common vision for what a high quality health system; reducing fragmentation and improving responsiveness; and finally, creating urgency while pacing interventions. Building on these principles, the project suggests reforming governance across financing and service delivery, strengthening revenue raising at all levels, increasing the size of the risk pools under a national insurance system, reorienting PBF towards an integrated definition of quality of care, and transforming the national health system towards strategic purchasing.