Knowledge Brief Health, Nutrition and Population Global Practice VERIFICATION OF PERFORMANCE IN RESULTS BASED FINANCING: THE CASE OF PANAMA’S PSPV PROGRAM Alfredo Perazzo, Carmen Carpio and Renzo Sotomayor August 2015 KEY MESSAGES: KEY MESSAGES  In 2013-2014, service coverage targets were generally achieved at a rate exceeding 90 percent, showing progress towards increased health equity in Panama.  Financial autonomy appears to be a determinant of performance, with non-profit providers meeting almost 78 percent of their performance targets while government institutions only achieve 16.1 percent of these targets. Qualitative evidence attributes this discrepancy to the additional resources and flexibility enjoyed by non-profit providers.  The complex, labor-intensive and disjointed nature of verification in Panama creates inefficiencies and leads to high transaction costs. It also shifts the focus from the achievement of results towards the completion of processes, in turn reducing the effectiveness of Results-Based Financing.  Context incentivizes health service providers for the delivery of two related health service packages: On average, Panama performs well on key health 1. The Integrated Package of Health Care Services, indicators with an infant mortality rate of 16 deaths per targeting indigenous communities; and 1,000 live births, an under-five mortality rate of 19 deaths 2. The Health Protection for Vulnerable Populations per 1,000 live births (World Bank, 2012), and a maternal Program (PSPV, for its Spanish acronym), targeting mortality ratio of 85 deaths per 100,000 live births (World the non-indigenous rural poor. Bank, 2013). These averages, however, mask disparities in health outcomes between urban and rural and indigenous areas. For example, in 2010, in the rural Introduction province of Bocas del Toro and in the indigenous area of Guna Yala, the under-five mortality rate was respectively This HNP Knowledge Brief focuses on the key findings of 2.6 and 0.6 times higher than the national average the World Bank case study entitled “Verification of (PAHO/MINSA, 2012). Performance in Results-Based Financing (RBF): The Case of Panama’s Health Protection for Vulnerable Over the past decade, the Government of Panama has Populations Program (PSPV)” (2014). used different RBF approaches to improve the coverage, quality and equity of health services, including the Health The case study covers 2011 and 2012 and concentrates Coverage Expansion Strategy (EEC). The EEC its analysis on data stemming from two sources: quarterly Page 1 HNPGP Knowledge Brief  reports produced during the verification process, and VERIFICATION MECHANISMS interviews conducted with stakeholders involved in the To ensure that targets are achieved, the PSPV includes implementation of the PSPV program. two verification mechanisms. The first verification is internal. Carried out quarterly by the Ministry of Health RBF PAYMENTS Under the PSPV, a portfolio of 15 incentivized indicators (MoH), this internal process requires mobile clinics to are delivered by (i) contracted non-profit providers (OEs) submit enrollment reports for the preparation of regional and (ii) government health professionals (GIs) working consolidated reports. These consolidated reports are then within basic health units (UBAs). Incentives are paid in verified by the MoH at central level (DPSS) for accuracy three ways: and completeness by comparing reports to information contained in the National Database of Civil Registration 1. Every two months based on the percentage of and Identity Cards. These figures provide the targets achieved for five coverage indicators (Table 1) during rural health visits (for example, mobile clinics). denominator for three coverage indicators, and for most This payment can represent a maximum of 65 percent service provision indicators. of the capitation rate. The second verification mechanism concerns third party Table 1: Coverage Indicators verification, whereby the government contracts a private firm. It includes three components: a) A quarterly verification of beneficiary-related data. As a first step, 100 percent of the records are checked against the beneficiary population register and against the Identification Verification System to ensure that information entered for each beneficiary is accurate and complete. A second level counter-verification is carried out on a 10 percent sample of beneficiaries, ensuring concordance of beneficiary records and beneficiary enrollment forms. 2. Every four months based on the achievement of ten b) The verification of the quantity of services is service-provision indicators (Table 2). Each indicator delivered by comparing the information is weighted equally and this payment can represent a contained in the EEC database against the maximum of 30 percent of the capitation rate. Identification Verification System. This verification 3. Every year based on the results of a patient- seeks to ensure that services reported in satisfaction survey. This payment represents five beneficiary records are actually delivered with percent of the capitation rate. each individual beneficiary having at least received one incentivized service. In parallel, the It is important to note that although there are no specific verification of quantity also includes a quarterly indicators linked to service quality, compliance with protocols is verification of the number of community visits an integral part of contracts signed with UBAs and as such, carried out and service days reported. This is quality is regularly verified. done by comparing UBA reports with health facility records and ensuring actual service Table 2: Performance Indicators delivery with a 10 percent sample (i.e. the same sample as the 10 percent checked for beneficiary enrollment). Compliance with treatment protocols is also verified. c) Social audits are carried out three times a year in all regions and in all of the UBAs to assess patient satisfaction. Page 2 HNPGP Knowledge Brief  Study Findings Although the study highlights the need to further extend Table 4: Indicators Accepted by the MOH and Rejected by the appropriate curative and preventive services to population groups, it shows progress in service coverage (Table 3): UBAs are reaching communities and delivering appropriate health services to children under 24 months. In addition, there is a clear improvement in the attendance of healthcare providers, with a 100 percent score in “days of services.” Table 3. UBAs RBF Service Coverage Indicators (2013-2014 Period) External Verifier, per Region (2011-2012) Lessons Learned In light of these mixed results, the case study draws Source: MOH-UGSAF Progress Report for the Period July 1, 2014 to several lessons and recommendations, highlighting December 31, 2014 further opportunities to improve RBF verification and performance. Nevertheless, service provision indicators highlight performance disparities between non-profit providers The RBF verification mechanisms of the PSPV employs (OEs) and government health professionals (GIs), with (a) multiple systems—the database of the overall health an average target achievement rate of 67 to 94 percent strategy, the MoH’s health information system and the among OEs for the first nine indicators; and (b) an Identification Verification System —which function in a average achievement rate of 11 to 23 percent among GIs. fragmented manner. At times, this fragmentation requires lengthy manual reviews, which increase workloads and The case study suggests that the high performance of heighten transaction costs. The case study draws the non-profit providers is attributable to greater access to following lessons: financial resources, enabling OEs to further invest in rural  The use of information technology systems should be health visits and providing them with added flexibility. better coordinated. The lack of coordination inherent The case study examines the difference between DPSS to health rounds and reporting increases the approved records and third party approved records (Table complexity and the inefficiency of both monitoring and 4). It indicates that differences have decreased between verification processes. This can delay payments and, 2011 and 2012, rarely exceeding 1 percent in 2012. This in turn, undermine the RBF incentivization system. suggests that the internal verification mechanism was performing well in 2012.  The third party verifier and the MoH need to be better aligned. Detailed verification of protocol compliance is critical to fully grasp the extent to which the PSPV’s provides added value.  The verification of protocol compliance has value beyond simply affecting payment. Further streamlining of payment and verification processes is needed. Currently, these processes involve many steps as well as many actors, amounting to the preparation of approximately 72 reports each quarter.  A simplification of payment and verification processes is needed to ensure a focus on the results achieved and not the processes. Page 3 HNPGP Knowledge Brief  References This HNP Knowledge Note highlights the key findings from a study by the World Bank on the “Verification of Performance in Results-Based Gesaworld. 2013. Propuesta Metodológica versión ajustada. Panama Financing (RBF): The Case of Panama’s Health Protection for Vulnerable Populations Program (PSPV)”, 2014. _____. 2012. Guía de Auditoría Técnica. Panama Gesaworld, Informes bimensuales y cuatrimestrales (varias ediciones) _____. 2012. Primer Informe de Auditoría Técnica Externa para la Certificación Del Padrón de Población Beneficiaria de la Estrategia de Extensión de Cobertura Periodo 2011 – 2012 – Versión Ajustada. Panama _____. 2012. Guía de Auditoría Administrativa Financiera. OLACEFS. 2008. Auditoría de los Programas Sociales. El Salvador Panama Ministry of Health and Pan-American Health Organization.. (2009-2010) Indicadores basicos de salud, panama 2009-2010. PAHO (Pan American Health Organization). 2012. Panama Country Chapter. Washington DC: Health in the Americas. Perazzo, A. 2012. Proyectos:”Mejora de la Equidad y Desempeño en Salud” y “Protección Social – Apoyo a las Redes de Oportunidades ». World Bank UNDP. 2013. Human Development Report. Available at: http://hdr.undp.org UGSAF. 2012. Caja de Herramientas para el agente de verificación. Panama _____. 2010. Provisión del PAISS+N y PSPV a través de giras institucionales - Reglamento operativo. Panama _____. 2010. Provisión del PAISS+N y PSPV a través de Organiaciones Extrainstitucionales - Reglamento operativo. Panama UGSAF. Evaluation Forms World Bank. 2013. World Bank Open Data. Available at: http://data.worldbank.org/country/panama _____. 2008. Project Appraisal Document (PAD), Health Equity and Performance Improvement Project. Washington, DC _____. 2007. Social Protection: Opportunities Network. Washington, DC The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4