1.
PBF and quality of care
The case of Burundi
Catherine Korachais*, Manassé Nimpagaritse, Kirrily de Polnay,
Bruno Meessen (ITM, Antwerp, Belgium)
November 2015, RBF workshop, Dar es Salaam

2.
BACKGROUND
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3.
• Free health care (reproductive and child health) since 2006:
• Assisted deliveries, antenatal care, family planning, etc.
• Immunisation, curative care for children under 5 years
• Performance Based Financing (PBF) nationwide since 2010
• At health centre and hospital levels
• PBF indicators coincide +/- free health care services (excl. Malnutrition)
• Funding: half from national budget, half from external
• In order to get more PBF subsides, health centres are encouraged to
improve their services (related to these indicators)
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Health care financing in Burundi

4.
• Growing literature on PBF
• Evidence on effects of PBF on health care utilisation in Burundi:
• No evidence on the effects of PBF on health outcomes yet
 That questions quality of care
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Rationale

5.
• Assess the quality of care in Burundi:
– Practice of health workers
– Knowledge “ “
– Know-do gap “ “
• Explore the determinants of quality of care
• Reflect on the role of PBF related to quality of care
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Objectives

6.
• We take the opportunity of an impact evaluation study
on PBF extended to Nutrition indicators
• 90 health centres take part in this study
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Data

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90 health centres have been
selected (among ≈200 eligible)

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• Baseline survey in health centres – end of 2014
– 90 health centres
– Content:
• Performance of malnutrition services - from clinical files: process and
output
• Organisational aspects of the health centre and of the nutrition
services
• Quality of services (patient-provider observations + exit-interviews)
• Knowledge of health workers (clinical case studies)
– Note: focus on paediatric curative consultations
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Data

9.
Yes No
Is the child able to drink or breastfeed?
Does the child vomit everything?
Has the child had convulsions?
Does the child have cough or difficulty breathing?
If yes, for how long?
Does the child have diarrhoea?
If yes, for how long?
If yes, is there blood in the stool?
Does the child have fever?
If yes, for how long?
If yes, what is the frequency of fever episodes?
Does the child have an ear problem?
Check the child's immunization
History
Has the question been
asked? If yes, what was the response?
Yes No
Is the child able to drink or breastfeed? P
Does the child vomit everything?
Has the child had convulsions?
Does the child have cough or difficulty breathing?
If yes, for how long?
Does the child have diarrhoea?
If yes, for how long?
If yes, is there blood in the stool?
Does the child have fever?
If yes, for how long?
If yes, what is the frequency of fever episodes?
Does the child have an ear problem?
Check the child's immunization
History
Has the question been
asked? If yes, what was the response?
Yes No
Is the child able to drink or breastfeed? P No
Does the child vomit everything?
Has the child had convulsions?
Does the child have cough or difficulty breathing?
If yes, for how long?
Does the child have diarrhoea?
If yes, for how long?
If yes, is there blood in the stool?
Does the child have fever?
If yes, for how long?
If yes, what is the frequency of fever episodes?
Does the child have an ear problem?
Check the child's immunization
History
Has the question been
asked? If yes, what was the response?
Yes No
Is the child able to drink or breastfeed? P No
Does the child vomit everything? P
Has the child had convulsions? P
Does the child have cough or difficulty breathing? P Yes, he's coughing
If yes, for how long? P
Does the child have diarrhoea? P
If yes, for how long? P
If yes, is there blood in the stool? P
Does the child have fever? P Yes
If yes, for how long? P 2 days
If yes, what is the frequency of fever episodes? P
Does the child have an ear problem? P
Check the child's immunization P
Has the question been
asked? If yes, what was the response?History
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Data: patient provider observations
Report on:
- History taking
- Exams
- Diagnosis
- Treatment
- Communication
X 6 / HC

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10
Data: vignettes
Yes No
Is the child able to drink or breastfeed? Yes
Does the child vomit everything? No
Has the child had convulsions? No
Does the child have cough or difficulty breathing? Yes
If yes, for how long? 5 days
Does the child have diarrhoea?
Not now, but it happened
some times during the last
two months
If yes, for how long? Not now
If yes, is there blood in the stool? No
Does the child have fever? Yes
If yes, for how long? Some days
He is sometimes very hot
History
Has the question been
asked? If yes, what was the response?
What would you do in this case:
A mother is coming to you, saying that her child is not going well
3 vignettes / HW
2 HWs/ HC

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• Do the HWs follow the IMCI guidelines?
• IMCI guidelines
– are in place in all heath centres in Burundi
– Aim: help HWs to quickly identify health problems of
children below 5 years old and to manage them
• Here we focus on the assessment part every HW
should perform
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Methodology

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For every child, IMCI guidelines recommend to:
• Ask the mother what the child’s problems are
• Check for
– general danger signs (questions)
– main symptoms (questions)
– vaccination status (questions)
– vital signs (exam)
– acute malnutrition status (exam)
• Here we’ve left aside:
– Particular assessment parts (e.g. items to check if diarrhoea)
– Diagnosis and treatment parts; communication aspects
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Methodology

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• Compute assessment questions and exams into scores
(counting items checked for), for each consultation and
for each vignette
– Overall score: 16 items
• Practice of HW = average score of consultations
• Knowledge of HW = average score of 3 vignettes
• Know-do gap of HW = Knowledge - Practice
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Methodology

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FINDINGS
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15.
• 145 health workers
– from 1 to 6 consultations observed by health worker
(total 515 consultations)
– 3 vignettes administered to each of them
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Data
Questionnaire Expected nb Collected
nb
Coverage Comment
Management
questionnaires
90 90 100%
Consultation 90 x 6 = 540 515 95% Not enough consultations in 10 HCs
Exit interview 90 x 6 = 540 512 95% Not enough consultations in 10 HCs
And 3 mothers lost
Vignettes 90 x 2 = 180 145 81% In 35 HCs: only one HW

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Characteristics of the health workers

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Consultations Vignettes
History
All three danger signs asked for 0% 0%
No danger sign asked for 60% 48%
All four ‘main symptoms’ asked for 4% 2%
No ‘main symptoms’ asked for 3% 4%
Vaccination status checked for 12% 16%
Physical exam
All three vital signs measured 0% 6%
No vital sign measured 37% 21%
All malnutrition status exams 3% 12%
No malnutrition status exam 34% 17%
Overall score (16 items; average in %) 28% 37%
Diagnosis
No correct diagnosis found out of 3 - 65%
All 3 diagnoses correct - 2%
N 145 145

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Overall score
With
consultations
With
vignettes
Difference
Know do gap
mean 28.0 37.4 9.5
median 25.0 33.3 8.3
min 4.2 10.4 -27.1
max 66.7 79.2 56.3
N 145 145 143
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Know-do gap

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Know-do gap
0
20406080
0 20 40 60 80
Vignette score
HW scores Fitted values
45 degree line

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Consultation score Vignette score Know-do gap
Age (base 20)
30-39 1.907 2.823 0.645
(3.727) (4.313) (2.924)
40-49 0.671 -1.335 -2.051
(5.509) (6.080) (4.467)
50+ -23.466*** -26.644** -2.929
(8.309) (10.355) (6.330)
Gender (base : female)
Male -6.555** 1.324 7.068**
(3.279) (3.820) (2.920)
Diploma (base : level A3)
Level A2 0.892 -1.814 -1.178
(4.533) (5.493) (4.019)
Level A1+ -8.101 -0.520 8.746
(10.087) (12.680) (5.945)
Supervision (base : none in the six last months)
Supervised -5.941* -8.212** -2.480
(3.206) (3.306) (2.948)
Training PBF (base : none)
Trained -0.345 -4.681 -4.123
(3.952) (4.628) (2.893)
Training Nutrition (base : none)
Trained 8.513*** 9.422** 1.484
(3.219) (3.658) (3.219)
Observations 115 117 115
R-squared 0.216 0.171 0.144
Note: variables controlled for but not significant are not displayed (employer type, HC type, wage, population pressure)
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Characteristics related to practice, knowledge & know-do gap

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• Poor level of health workers’ performance, both
through observations of consultations and vignettes
• Know-do gap exists, though it seems rather low and less
urgent than knowledge issues
• Poor knowledge results call for more and better training
and supervision of health workers
• From these data, it’s impossible to assess PBF influence
on quality of care – but strongly suggests that PBF alone
(or without a real quality of care assessment module) is
not enough to improve health outcomes
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Summary of findings

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• Low number of consultations per health worker,
Hawthorne effect
• Could go further with the score, with including:
– Quality of management of cases of diarrhoea, fever, cough,
ear problems
– Treatment decisions according to diagnoses
– Communication aspects
• Other dimensions of quality of care
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Limitations