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1、N!PAYMENTINCENTIVESFORIMPROVEDQUALITYOFHEALTHSERVICE!DELIVERYINREPUBLIKASRPSKAANDaiTHEFEDERATIONOFBOSNIAANDHERZEGOVINASenad HuseinagicSinisa Stevic Charles Birungi Adanna ChukwumaPa ZUouJnsoosQo=qndworldBankgroupHealth,Nutrition&PopulationPAYMENTINCENTIVESFORIMPROVEDQUALITYOFHEALTHSERVICEDELIVERYINR
2、EPUBLIKASRPSKAANDTHEFEDERATIONOFBOSNIAANDHERZEGOVINASenadHuseinagicSinisaStevicCharlesBirungiAdannaChukwumaApril2023Health,Nutrition,andPopulation(HNP)DiscussionPaperThisseriesisproducedbytheHealth,Nutrition,andPopulationGlobalPracticeoftheWorldBank.Thepapersinthisseriesaimtoprovideavehicleforpublis
3、hingpreliminaryresultsonHNPtopicstoencouragediscussionanddebate.Thefindings,interpretations,andconclusionsexpressedinthispaperareentirelythoseoftheauthor(s)andshouldnotbeattributedinanymannertotheWorldBank,toitsaffiliatedorganizations,ortomembersofitsBoardofExecutiveDirectors,ortothecountriestheyrep
4、resent.Citationandtheuseofthematerialpresentedinthisseriesshouldtakeintoaccountthisprovisionalcharacter.TheWorldBankdoesnotguaranteetheaccuracyofthedataincludedinthiswork.Theboundaries,colors,denominations,andotherinformationshownonanymapinthisworkdonotimplyanyjudgmentonthepartoftheWorldBankconcerni
5、ngthelegalstatusofanyterritoryortheendorsementoracceptanceofsuchboundaries.ForinformationregardingtheHNPDiscussionPaperSeries,pleasecontacttheEditor,Jung-HwanChoiatichoiwOrldbank.ororErikaYanickatevanickVVorldbank.orn.RIGHTSANDPERMISSIONSThematerialinthisworkissubjecttocopyright.BecausetheWorldBanke
6、ncouragesthedisseminationofitsknowledge,thisworkmaybereproduced,inwholeorinpart,fornoncommercialpurposesaslongasfullattributiontothisworkisgiven.Anyqueriesonrightsandlicenses,includingsubsidiaryrights,shouldbeaddressedtoWorldBankPublications,TheWorldBankGroup,1818HStreet,NW,Washington,DC20433,USA;fa
7、x:202-522-2625;e-mail:pubrightsworldbank.orgHealth,NutritionandPopulation(HNP)DiscussionPaperPaymentincentivesforimprovedqualityofhealthservicedeliveryinRepublikaSrpskaandtheFederationofBosniaandHerzegovinaSenadHuseinagicaSinisaStevicbCharlesBirungicdAdannaChukwumaeaHealthEconomist,Health,Nutrition,
8、andPc)PUIatiOnGlobalPractice,WorldBank,Washington,DC,UnitedStates.bHealthEconomist,Health,Nutrition,andPopulationGlobalPractice,WorldBank,Washington,DC,UnitedStates.cHealthEconomist,Health,Nutrition,andPopulationGlobalPractice,WorldBank,Washington,DC,UnitedStates.dFellow,TheUCLCentreforGlobalHealthE
9、conomics,UniversityCollegeLondon,London,UnitedKingdom.eSeniorHealthEconomist,Health,Nutrition,andPopulationGlobalPractice,WorldBank,Washington,DC,UnitedStates.Abstract:Thisreportoutlinesastrategicapproachtointroducepay-for-performance(P4P)incentivesforimprovednoncommunicabledisease(NCD)careinRepubli
10、kaSrpska(RS)andtheFederationofBosniaandHerzegovina(FBiH).DevelopedundertheHealthSystemsImprovementProject(HSIP)andMuIti-DonorTrustFund(MDTF)forHealthSystemsReform,theapproachfocusesonevidence-based,technicallysound,andpoliticallyfeasiblestrategies.Participatorilydeveloped,thereportsynthesizesgloball
11、essonsandanalyzesthepolicyenvironmentinRSandFBiH.Itproposeskeydesignfeatures,addressingstrategicopportunitiesandoperationalchallenges.Behavioraleconomicsinsightsandpoliticaleconomyfactorsinformtheapproach,identifyingkeylevers,opportunities,andchallengesaffectingP4Pimplementationcapacity.ToenhanceNCD
12、carequality,thereportrecommendschangesintheproviderpaymentmix,tailoredreformsatentityandcantonallevels,andactiveserviceuserengagement.Emphasizingtheimportanceoflinkingpaymentincentivestoperformance,theproposeddesignspansdimensionssuchasperformancemeasures,basisofpayment,paymentattributes,recipientof
13、payment,andtargetedoutcomes.Anenablingenvironmentisdeemedcritical.Relatedly,effectiveimplementationrequiresrobustdatasystems,stakeholderengagement,adaptedlegalframeworks,andsuitableinstitutionalarrangements.Technicalassistanceandbudgetarysupportneedsareidentified.ItisexpectedthatP4Pimplementationwil
14、lenhanceNCDcarecoverageandquality,therebyimprovinghealthoutcomesandoverallhealthsystemperformanceinRSandFBiH.Keywords:Healthfinancing,qualityofcare,pay-for-performance,noncommunicabledisease,BosniaandHerzegovina.Disclaimer:Thefindings,interpretationsandconclusionsexpressedinthepaperareentirelythoseo
15、ftheauthors,anddonotrepresenttheviewsoftheWorldBank,itsExecutiveDirectors,orthecountriestheyrepresent.CorrespondenceDetails:AdannaChukwuma,1818HStreet,NW,WashingtonDC20043,USA,Tel:+1(202)2129000,Email:achukwumawOrIdbank.orq,Website:TableofContentsAcknowledgmentsvAcronymsandabbreviationsviExecutiveSu
16、mmaryviiI. Introduction1II. CountryandSectorContext4A. PoliticalandEconomicContext4B. HealthSystemsPerformance5C. DemographicTrends9D. HealthGovernance10E. ServiceDelivery10F. HealthFinancing12G. DesignImplications17III. PaymentMethodology19A. Objectives19B. Measurement19C. Incentives19D. Adjustment
17、s20E. Recipients21F. Periodicity21IV. EnablingEnvironment23A. DataSystems23B. StakeholderEngagement23C. StakeholderRoles24D. RegulatoryFramework25E. BudgetaryNeeds27F. RolloutTimeLine27References29AcknowledgmentsThisapproachpaperwasdevelopedbyateamledbyAdannaChukwuma(HECHN),withsignificantcontributi
18、onsfromWorldBankconsultantsSenadHuseinagic(HECHN)5SinisaStevic(HECHN),andCharlesBirungi(HECHN).TheauthorsaregratefultotheWorldBankforpublishingthisreportasanHNPDiscussionPaper.TheroadmapdrawsoninsightsfromworkinggroupsinRepublikaSrpska(RS)andtheFederationofBosniaandHerzegovina(FBiH)5includingreprese
19、ntativesoftheMinistryofHealthandSocialWelfare(MoHSW)oftheRS;theFederationMinistryofHealth(FMoH);theRSHealthInsuranceFund(HIF);FederalandCantonalHIFsintheFBiH;theAgencyforQualityandAccreditationinHealthcare(AKAZ)oftheFBiH;theAgencyforCertification,Accreditation,andHealthCareImprovement(ASKVA)oftheRS;
20、andCantonalMinistriesofHealth.ThehealthsystemsanalysisbuildsonrecentworkbytheWorldHealthOrganization(WHO2022)andfeedbackfromShomikhoRaha(EECG2),AliHamandi(HECHN)1andIsidoreSieleunou(HHNGF).RichardCrabbe(HECHN)providededitorialservices.ThisworkisaproductofthestaffoftheWorldBank.Thefindings,interpreta
21、tions,andconclusionsexpressedinthisworkdonotnecessarilyreflecttheviewsoftheWorldBank,itsBoardofExecutiveDirectors,orthegovernmentstheyrepresent.TheWorldBankdoesnotguaranteetheaccuracyofthedataincludedinthiswork.Theboundaries,colors,denominations,andotherinformationshownonanymapinthisworkdonotimplyan
22、yjudgmentonthepartoftheWorldBankconcerningthelegalstatusofanyterritoryortheendorsementoracceptanceofsuchboundaries.AcronymsandabbreviationsAKAZAgencyforQualityandAccreditationinHealthcareoftheFederationofBosniaandHerzegovinaASKVAAgencyforCertification,Accreditation,andHealthCareImprovementofRepublik
23、aSrpskaKMBiHVID-19CVDDBDRGHEREUFBiHFFSFMFMoHGDPHIFHSIPIHDITIZISLEMoFMoHMoHSWNCDsOECDOOPP4PPHCPHIPPPQlBosnia-HerzegovinaConvertibleMark(officialcurrency)BosniaandHerzegovinaCommonwealthofIndependentStatesCoronavirusdiseasecardiovasculardiseaseDistrictofBrckoDiagnosis-RelatedGroupElectronichealthrecor
24、dEuropeanUnionFederationofBiHFee-for-serviceFamilymedicineFederalMinistryofHealthGrossDomesticProductHealthInsuranceFundHealthSystemsImprovementProjectIschemicheartdiseaseInformationTechnologyIntegratedHealthInformationSystem1.ifeexpectancyMinistryofFinanceMinistryofHealthMinistryofHealthandSocialWe
25、lfareNoncommunicablediseasesOrganisationforEconomicCo-operationandDevelopmentOut-of-pocketpaymentPay-for-performancePrimaryHealthCarePublicHealthInstitutePurchasingPowerParityQualityIndicatorsQoCRSSEEUHCUMICWBGWHOQualityofcareRepublicofSrpskaSoutheasternEuropeUniversalhealthcoverageUpper-Middle-Inco
26、meCountryWorldBankGroupWorldHealthOrganizationExecutiveSummaryThisreportpresentsanapproachtoimplementingpaymentincentivesforimprovedqualityofhealthservicedeliveryinRepublikaSrpska(RS)andtheFederationofBosniaandHerzegovina(FBiH).Itdetailsapracticaloperationalroadmapforimplementingpay-for-performance(
27、P4P)asapurchasingmechanisminhealth,proposeskeydesignfeatures,andidentifiesthekeyissuesandareasthatRSandtheFBiHshouldfocusonforsuccessfulimplementation.Itservesasaninitialframeworkfortheentity-levelmethodologicaldocumentstobedevelopedundertheHealthSystemsImprovementProject(HSIP)andtheMulti-DonorTrust
28、Fund(MDTF)forHealthSystemsReform.Itismotivatedbytherecognitionthattheimpactofcurrentproviderpaymentmethodsonnoncommunicabledisease(NCD)preventionandcareremainslimitedduetoinadequatepaymentincentivesforimprovedaccessandquality.Anevidence-based,technicallysound,andpoliticallyfeasibleapproachisproposed
29、.Theapproachbuildsonacomprehensivereviewandsynthesisoflessonsfrompastandongoingimplementationoffinancialincentivesforimprovingeffectivecoverageinhealthinothercountries;ananalysisofthecurrentpolicyenvironmentandpoliticaleconomyforreform;andtheensuingkeyinstitutional,legislative,andpolicyopportunities
30、andbottlenecks;studytourstotheRepublicofSerbiaandtheUnitedKingdom(UK)byRSandtheFBiH1respectively;andkeyinformantinterviewsaswellasconsultationswithvariouskeystakeholders.TheproposedP4Pdesignfeaturesleverageidentifiedstrategicopportunitiesandaddressoperationalchallenges.Informedbytheaboveandconsideri
31、ngbehavioraleconomicsinsightsandpoliticaleconomyfactors,theapproachpresentedinthisreportidentifiesasetofkeylevers,bindingconstraints,andoperationalchallengesthatcanaffectthecapacityoftheentitiestoimplementpaymentincentivesforimprovedqualityofNCDcare.Recognizingthese,thereportrecommendsasetofstrategi
32、cdesignfeaturesandpolicyreforminitiativesfocusedonintroducing,strengthening,andinstitutionalizingtheP4Pmechanism.Drawingontheeconomicsofcontracts,italsorecognizestheimportanceofpoliticaleconomyissuesandproposestailoredtechnicalassistanceneedstostrengthencapacityforadaptation,adoption,andimplementati
33、on.Therefore,thecorrespondingimplicationsfortheproposeddesignfeaturesincludethefollowing: Changesinthepaymentmixshouldcontributetotacklingchallengesinthehealthsystems. Thecomplexadministrativeandhealthsystemsstructureimpliesthatpaymentreformsshouldbetailoredattheentityandcantonallevels(fortheFBiH).
34、TheprimarypurchaserwillplayasignificantroleintheimplementationofP4P.Theroleofserviceusersshouldshiftfrompassiveconsumptiontoactiveengagement.1.inkingpaymentincentivestoperformanceiskeyforimpactonaccesstoandqualityofNCDcare.Toexplicitlylinkpaymentincentivestoperformance,theproposeddesignfeaturesspant
35、hefollowingkeydimensions:performancemeasures,basisofpayment,paymentattributes,recipientofpayment,andtargetedoutcomes.Qualityofcare(QoC)istheperformancemeasure,spanningstructure,process,andoutcomemeasures.Forcost-effectiveimplementationandtoinstitutionalizeP4P,indicatorsofQoCW川bedrawnfromexistingsyst
36、emstheAgencyforCertification,Accreditation,andHealthCareQualityImprovementoftheRSandtheAgencyforAccreditationandQualityinHealthoftheFBiHanddifferbyservicedeliverylevel.ThiswillhappenundertheHSIPasperthelegalagreement.Asabasisforpayment,aformula-basedcontinuousthresholdmethodologyandanappropriatequal
37、itativerisk-adjustmentapproachisproposedtoincentivizecontinuousperformanceimprovementbyrewardingeachactivityundertaken.Regardingpaymentattributes,tostimulatelargerbehavioralresponses,bonuseswillbegivenandlinkedtoperformanceagainsttheselectedindicators.Giventhelowlevelsofproviderremuneration,nopenalt
38、ieswillbeimposed.Regardingrecipientofpayment,theincentivepaymentswillbedirectedtowardhealthprofessionalsinfamilymedicineteams.Finally,improvedpreventionandcontrolofNCDsisthetargetedoutcome.AnenablingenvironmentisanecessaryconditionforeffectiveP4Pimplementation.Inlinewiththeagreementtoundertakethepro
39、posedproviderpaymentreformthroughtheHSIPoperation,itisdesignedtobeimplementedinphasesovertheperiod2023to2026.Startingasapilot,reformwilleventuallybescaleduptocompletelycovertherespectiveentities,usingdatafrommonitoringthepilotstoinformchangestotheprograms.Thereportcallsforanenablingenvironmenttoward
40、robustdatasystems,meaningfulstakeholderengagement,adaptedlegalandregulatoryframework,andappropriateinstitutionalarrangements.Here,themainelementsofaneffectiveP4Pinterventioncouldincludeadaptingthelegalframework,buildingsupportfromprofessionalgroups,systematicstakeholderengagement,educationandtrainin
41、goffacilitymanagers,(further)developmentofP4Pmethodology,establishingworkingandcoordinationcommittees,andallocatingsufficientbudgetaryandfinancialresources.FullyleveragingP4Pforimprovedhealthsystemsperformancewillrequiretargetedhigh-qualitytechnicalsupport.TosupportrolloutofP4PinRSandtheFBiH,therepo
42、rtdetailstechnicalassistanceneeds.Thesemayincludedraftingthelegalandregulatoryframeworkchanges;developingtheP4Pmethodology;costingtheimplementationofP4P;advisingonthedesignofincentives,adjustments,andotherelements;designingthetrainingcurriculumforfacilitymanagersandotherstakeholders;andadaptingtheel
43、ectronichealthrecords(EHR)module.Thesehavebudgetaryimplications,withsupportenvisagedtobeprovidedundertheHSIP,theWorldBankMulti-DonorTrustFund(MDTF),andviatheannualbudgetsoftheMinistryofHealthandSocialWelfare(MoHSW)andtheMinistryofHealth(MoH)ofRSandtheFBiH1respectively.Thispaperisapreliminarystudytha
44、t,undertheMDTF5willbefollowedwithdevelopingformalinputstosupportthechangesunderHSIP,withtheinputssubmittedtotheMinistryofFinanceofBiH1entity-levelMoHs5andtheHealthInsuranceFund(HIF).Finally,comparedwithbusinessasusual,P4PimplementationintheRSandtheFBiHisenvisagedtonotonlyimprovethecoverageofNCDcareb
45、utalsotheQoCprovided.Thiswillimprovehealthoutcomesandoverallhealthsystemsperformance.I.IntroductionThisreportpresentsanapproachtoimplementingpaymentincentivesforimprovedqualityofservicedeliveryinRepublikaSrpska(RS)andtheFederationofBosniaandHerzegovina(FBiH).Basedonextensivestakeholderconsultations,
46、synthesisoftheliteratureonpay-for-performance(P4P)mechanisms,andstudytourstolearnfromcountrieswithestablishedP4Psystems, The RS to the Republic of Serbia and the FBiH to the United Kingdom.thisdocumentwasdevelopedwithinthentextoftheFunctionalReviewofHealthSystems*PerformanceProgram(P167607)bytheWorl
47、dBankGroup(WBG).Itservesasaninitialframeworkfortheentity-levelmethodologicaldocumentstobeproducedundertheHealthSystemsImprovementProject(HSIPP171150)andtheWorldBank,sMulti-DonorTrustFund(MDTF)forHealthSystemsReform.ItsdevelopmentprocessinvolvedrepresentativesoftheMinistryofHealthandSocialWelfare(MoH
48、SW)oftheRSandtheFederationMinistryofHealth(FMoH)(hereinafterreferredtoastheMinistriesofHealthMoHs);theHealthInsuranceFunds(HIFs);theAgencyforQualityandAccreditationinHealthcare(AKAZ)oftheFBiH;theAgencyforCertification,Accreditation,andHealthCareImprovement(ASKVA)ofRS;andrepresentativesofhealthcareproviders.ThehealthsystemsinBiHperformavitalsocialsecurityfunction.Theysignificantlycontributetosocialandeconomicwelfarebymitigatinghealthandfiscalrisks.Beforethecoronavirusdisease(COVID-19)pandemic,lifeexpectancyinBiHwasclosetotheSoutheasternEuropean(SEE)This includes Albania, BiH, Bulgaria, Croatia
