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Paying for performance in Rwanda: evidence from DHS data on rewarded services, multitasking, and health outcomes
Performance-based contracting based on inputs is particularly challenging in complex settings such as health care, where issues such as joint production, multiple agents in production, and market failures compound the critical contracting concern of multitasking. We analyze the impacts of Rwanda’s national pay-for-performance (P4P) program, where health care facilities were offered performance bonuses based on process measures of health care quality. Using two waves of data from the Rwanda Demographic and Health Surveys, collected before and after the randomized roll-out of P4P, in a difference-in-differences analysis we find that the P4P program improved some rewarded services, had weakly positive impacts on several unrewarded services, and had no impact on health outcomes. We find no evidence of multitasking, and find mixed effects of the program by baseline levels of quality, with most of the improvements seen in the middle quality tier.
Manoj Mohanan is Assistant Professor of Public Policy and Global Health at the Sanford School of Public Policy at Duke University. His current research projects include experimental evaluation of financial and nonfinancial incentives in health care, development of new tools to measure quality of care, impact evaluation of large public sector subsidy programs, evaluation of social franchising models, and estimating the effect of quality and prices on households' choice of providers. He is a co-founder of COHESIVE-India: The Collaboration for Health Systems Improvement and Impact Evaluation in India. He received his PhD in Health Policy (Economics) from the Graduate School of Arts and Sciences at Harvard University and also holds degrees in medicine (Grant Medical College, Mumbai) and public health (Harvard School of Public Health).