Jean-Pierre Unger (ITM)
PBF, ostensibly a motivating technique, consists of payment per service, in theory with a productivity goal. It is also said to be a technique to reform / restructure health care systems.
From a descriptive, political economy angle, PBF can be viewed as a simplified version of econometric methods applied to cost health care activities, which is needed to contract health care activities in the context of policies based on a purchaser-provider split. As such, it paves the way for the introduction of elaborated managed care techniques within public health services and care commoditization.
Importantly, Musgrove defined PBF as encompassing control of paid production. PBF sustainability is, however, everywhere an issue as middle- and even high-income countries are not capable of controlling the quantity of services provided and even less their quality. Here are some examples:
- The HESVIC project (2009-2012) studied governance, regulation and control of maternal health activities in Vietnam, India and China. It concluded that of 9 such case studies, 8 revealed large-scale regulatory failure and only one showed relative success. But this last achievement was due to public control intertwined with central planning techniques;
- Latin American countries with lengthy experience in health care commoditization (e.g. Chile; Colombia ) failed to make their systems efficient i.e. because of weak regulation;
- Costa Rica used a mild form of PBF: upon productivity assessment, its public health facilities received additional resources to improve care. Although relatively mild, these ‘management contracts’ seriously hampered access to and quality of acute care (W.Soors, P.De Paepe, JP Unger. Management Commitments and Primary Care: another Lesson from Costa Rica for the World? Int J Health Services, 2011, in press).
- The mechanisms linking regulation failures and LMIC characteristics have been discussed at length elsewhere. In spite of possible positive projects in LIC and failed states, there are reasons to believe that PBF won’t be sustainable unless the international agenda is to make LIC health systems rely in the long-term on international aid: reproducibility of pilot projects in situations where development aid is not the dominant source of health system financing remains dubious.
Even in LIC, PBF may lack valid evidence. Apparent successes in Rwanda, for instance, can be explained by characteristics of the health system itself, e.g. a decently financed public system. The initial low income level of health workers probably also explains to some degree PBF effectiveness, as PBF helps to increase the revenue of care providers.
The key problem with PBF, however, concerns effectiveness and ethics. Indeed, PBF may work against care quality while distorting the professional identity of health workers and professionals (nurses, clinical officers, medical assistants and doctors) because it relies on the assumption that they are merely economic actors and contributes in fact to making them so in some kind of a self-fulfilling prophecy.
Instead of comparing PBF intervention groups with a control group, it would have made more sense to compare PBF groups with other ones that are subject to strategies designed to reinforce professionalism in health systems. Indeed, although professional skills and identity cannot be measured and as such are not easily taken into account by the economic and epidemiologic sciences, they are key conditions of care quality since good consultations entail
- Complex decision making as in bio-psychosocial care, which is an issue of family medicine;
- Ethos, with a praxis referring to a complex ethical system, which is a philosophical issue;
- Acquiring manual and behavioral skills, a psycho-pedagogical issue;
- Reflective methods in care delivery (such as audit, supervision, intervision, action research, etc), which involves medical knowledge.
Economists tend to gather all these care components under one (supposedly measurable) umbrella concept – responsiveness, see the WHO 2000 classification of countries’ performance – which reveals the knowledge limits of this science when it comes to care quality.
Besides a sociopolitical concern for equity, ethics, communication, skills, reflectivity and symbolic motivation of health professionals (a component of their intrinsic motivation) are all dimensions that should help structure health systems aiming to deliver individual health care.
Because experience with managed care techniques and disease control programs shows that they harm professional identity and the delivery of bio-psychosocial care, economic techniques such as capitation and PBF taken in isolation should not be permitted to structure health care systems. Rather, patients’ care trajectories, co-management and ethically inspired professionalism should.
To improve professional clinical decision making, in particular complex decisions related to the delivery of bio-psychosocial care as in family medicine practice, many non-managed care techniques exist (see International Health and Aid Policies – The Need for Alternatives (2010), chapter 19. Non-managed care techniques to improve clinical decision making Section 1. Versatile techniques Section 2. Interface flow-process audit).
Further (action-)research and experiences are needed to develop such reflexive tools designed also to enhance their users’ professional identity.