世界银行-塞族共和国和波斯尼亚和黑塞哥维那联邦提高卫生服务质量的付款激励措施（英）-2023..docx

N!PAYMENTINCENTIVESFORIMPROVEDQUALITYOFHEALTHSERVICE!DELIVERYINREPUBLIKASRPSKAANDaiTHEFEDERATIONOFBOSNIAANDHERZEGOVINASenad HuseinagicSinisa Stevic Charles Birungi Adanna ChukwumaPa ZUou<JnsoosQo=qndworldBankgroupHealth,Nutrition&PopulationPAYMENTINCENTIVESFORIMPROVEDQUALITYOFHEALTHSERVICEDELIVERYINREPUBLIKASRPSKAANDTHEFEDERATIONOFBOSNIAANDHERZEGOVINASenadHuseinagicSinisaStevicCharlesBirungiAdannaChukwumaApril2023Health,Nutrition,andPopulation(HNP)DiscussionPaperThisseriesisproducedbytheHealth,Nutrition,andPopulationGlobalPracticeoftheWorldBank.ThepapersinthisseriesaimtoprovideavehicleforpublishingpreliminaryresultsonHNPtopicstoencouragediscussionanddebate.Thefindings,interpretations,andconclusionsexpressedinthispaperareentirelythoseoftheauthor(s)andshouldnotbeattributedinanymannertotheWorldBank,toitsaffiliatedorganizations,ortomembersofitsBoardofExecutiveDirectors,ortothecountriestheyrepresent.Citationandtheuseofthematerialpresentedinthisseriesshouldtakeintoaccountthisprovisionalcharacter.TheWorldBankdoesnotguaranteetheaccuracyofthedataincludedinthiswork.Theboundaries,colors,denominations,andotherinformationshownonanymapinthisworkdonotimplyanyjudgmentonthepartoftheWorldBankconcerningthelegalstatusofanyterritoryortheendorsementoracceptanceofsuchboundaries.ForinformationregardingtheHNPDiscussionPaperSeries,pleasecontacttheEditor,Jung-HwanChoiatichoiwOrldbank.ororErikaYanickatevanickVVorldbank.orn.RIGHTSANDPERMISSIONSThematerialinthisworkissubjecttocopyright.BecausetheWorldBankencouragesthedisseminationofitsknowledge,thisworkmaybereproduced,inwholeorinpart,fornoncommercialpurposesaslongasfullattributiontothisworkisgiven.Anyqueriesonrightsandlicenses,includingsubsidiaryrights,shouldbeaddressedtoWorldBankPublications,TheWorldBankGroup,1818HStreet,NW,Washington,DC20433,USA;fax:202-522-2625;e-mail:pubrightsworldbank.orgHealth,NutritionandPopulation(HNP)DiscussionPaperPaymentincentivesforimprovedqualityofhealthservicedeliveryinRepublikaSrpskaandtheFederationofBosniaandHerzegovinaSenadHuseinagicaSinisaStevicbCharlesBirungicdAdannaChukwumaeaHealthEconomist,Health,Nutrition,andPc)PUIatiOnGlobalPractice,WorldBank,Washington,DC,UnitedStates.bHealthEconomist,Health,Nutrition,andPopulationGlobalPractice,WorldBank,Washington,DC,UnitedStates.cHealthEconomist,Health,Nutrition,andPopulationGlobalPractice,WorldBank,Washington,DC,UnitedStates.dFellow,TheUCLCentreforGlobalHealthEconomics,UniversityCollegeLondon,London,UnitedKingdom.eSeniorHealthEconomist,Health,Nutrition,andPopulationGlobalPractice,WorldBank,Washington,DC,UnitedStates.Abstract:Thisreportoutlinesastrategicapproachtointroducepay-for-performance(P4P)incentivesforimprovednoncommunicabledisease(NCD)careinRepublikaSrpska(RS)andtheFederationofBosniaandHerzegovina(FBiH).DevelopedundertheHealthSystemsImprovementProject(HSIP)andMuIti-DonorTrustFund(MDTF)forHealthSystemsReform,theapproachfocusesonevidence-based,technicallysound,andpoliticallyfeasiblestrategies.Participatorilydeveloped,thereportsynthesizesgloballessonsandanalyzesthepolicyenvironmentinRSandFBiH.Itproposeskeydesignfeatures,addressingstrategicopportunitiesandoperationalchallenges.Behavioraleconomicsinsightsandpoliticaleconomyfactorsinformtheapproach,identifyingkeylevers,opportunities,andchallengesaffectingP4Pimplementationcapacity.ToenhanceNCDcarequality,thereportrecommendschangesintheproviderpaymentmix,tailoredreformsatentityandcantonallevels,andactiveserviceuserengagement.Emphasizingtheimportanceoflinkingpaymentincentivestoperformance,theproposeddesignspansdimensionssuchasperformancemeasures,basisofpayment,paymentattributes,recipientofpayment,andtargetedoutcomes.Anenablingenvironmentisdeemedcritical.Relatedly,effectiveimplementationrequiresrobustdatasystems,stakeholderengagement,adaptedlegalframeworks,andsuitableinstitutionalarrangements.Technicalassistanceandbudgetarysupportneedsareidentified.ItisexpectedthatP4PimplementationwillenhanceNCDcarecoverageandquality,therebyimprovinghealthoutcomesandoverallhealthsystemperformanceinRSandFBiH.Keywords:Healthfinancing,qualityofcare,pay-for-performance,noncommunicabledisease,BosniaandHerzegovina.Disclaimer:Thefindings,interpretationsandconclusionsexpressedinthepaperareentirelythoseoftheauthors,anddonotrepresenttheviewsoftheWorldBank,itsExecutiveDirectors,orthecountriestheyrepresent.CorrespondenceDetails:AdannaChukwuma,1818HStreet,NW,WashingtonDC20043,USA,Tel:+1(202)2129000,Email:achukwumawOrIdbank.orq,Website:TableofContentsAcknowledgmentsvAcronymsandabbreviationsviExecutiveSummaryviiI. Introduction1II. CountryandSectorContext4A. PoliticalandEconomicContext4B. HealthSystemsPerformance5C. DemographicTrends9D. HealthGovernance10E. ServiceDelivery10F. HealthFinancing12G. DesignImplications17III. PaymentMethodology19A. Objectives19B. Measurement19C. Incentives19D. Adjustments20E. Recipients21F. Periodicity21IV. EnablingEnvironment23A. DataSystems23B. StakeholderEngagement23C. StakeholderRoles24D. RegulatoryFramework25E. BudgetaryNeeds27F. RolloutTimeLine27References29AcknowledgmentsThisapproachpaperwasdevelopedbyateamledbyAdannaChukwuma(HECHN),withsignificantcontributionsfromWorldBankconsultantsSenadHuseinagic(HECHN)5SinisaStevic(HECHN),andCharlesBirungi(HECHN).TheauthorsaregratefultotheWorldBankforpublishingthisreportasanHNPDiscussionPaper.TheroadmapdrawsoninsightsfromworkinggroupsinRepublikaSrpska(RS)andtheFederationofBosniaandHerzegovina(FBiH)5includingrepresentativesoftheMinistryofHealthandSocialWelfare(MoHSW)oftheRS;theFederationMinistryofHealth(FMoH);theRSHealthInsuranceFund(HIF);FederalandCantonalHIFsintheFBiH;theAgencyforQualityandAccreditationinHealthcare(AKAZ)oftheFBiH;theAgencyforCertification,Accreditation,andHealthCareImprovement(ASKVA)oftheRS;andCantonalMinistriesofHealth.ThehealthsystemsanalysisbuildsonrecentworkbytheWorldHealthOrganization(WHO2022)andfeedbackfromShomikhoRaha(EECG2),AliHamandi(HECHN)1andIsidoreSieleunou(HHNGF).RichardCrabbe(HECHN)providededitorialservices.ThisworkisaproductofthestaffoftheWorldBank.Thefindings,interpretations,andconclusionsexpressedinthisworkdonotnecessarilyreflecttheviewsoftheWorldBank,itsBoardofExecutiveDirectors,orthegovernmentstheyrepresent.TheWorldBankdoesnotguaranteetheaccuracyofthedataincludedinthiswork.Theboundaries,colors,denominations,andotherinformationshownonanymapinthisworkdonotimplyanyjudgmentonthepartoftheWorldBankconcerningthelegalstatusofanyterritoryortheendorsementoracceptanceofsuchboundaries.AcronymsandabbreviationsAKAZAgencyforQualityandAccreditationinHealthcareoftheFederationofBosniaandHerzegovinaASKVAAgencyforCertification,Accreditation,andHealthCareImprovementofRepublikaSrpskaKMBiHVID-19CVDDBDRGHEREUFBiHFFSFMFMoHGDPHIFHSIPIHDITIZISLEMoFMoHMoHSWNCDsOECDOOPP4PPHCPHIPPPQlBosnia-HerzegovinaConvertibleMark(officialcurrency)BosniaandHerzegovinaCommonwealthofIndependentStatesCoronavirusdiseasecardiovasculardiseaseDistrictofBrckoDiagnosis-RelatedGroupElectronichealthrecordEuropeanUnionFederationofBiHFee-for-serviceFamilymedicineFederalMinistryofHealthGrossDomesticProductHealthInsuranceFundHealthSystemsImprovementProjectIschemicheartdiseaseInformationTechnologyIntegratedHealthInformationSystem1.ifeexpectancyMinistryofFinanceMinistryofHealthMinistryofHealthandSocialWelfareNoncommunicablediseasesOrganisationforEconomicCo-operationandDevelopmentOut-of-pocketpaymentPay-for-performancePrimaryHealthCarePublicHealthInstitutePurchasingPowerParityQualityIndicatorsQoCRSSEEUHCUMICWBGWHOQualityofcareRepublicofSrpskaSoutheasternEuropeUniversalhealthcoverageUpper-Middle-IncomeCountryWorldBankGroupWorldHealthOrganizationExecutiveSummaryThisreportpresentsanapproachtoimplementingpaymentincentivesforimprovedqualityofhealthservicedeliveryinRepublikaSrpska(RS)andtheFederationofBosniaandHerzegovina(FBiH).Itdetailsapracticaloperationalroadmapforimplementingpay-for-performance(P4P)asapurchasingmechanisminhealth,proposeskeydesignfeatures,andidentifiesthekeyissuesandareasthatRSandtheFBiHshouldfocusonforsuccessfulimplementation.Itservesasaninitialframeworkfortheentity-levelmethodologicaldocumentstobedevelopedundertheHealthSystemsImprovementProject(HSIP)andtheMulti-DonorTrustFund(MDTF)forHealthSystemsReform.Itismotivatedbytherecognitionthattheimpactofcurrentproviderpaymentmethodsonnoncommunicabledisease(NCD)preventionandcareremainslimitedduetoinadequatepaymentincentivesforimprovedaccessandquality.Anevidence-based,technicallysound,andpoliticallyfeasibleapproachisproposed.Theapproachbuildsonacomprehensivereviewandsynthesisoflessonsfrompastandongoingimplementationoffinancialincentivesforimprovingeffectivecoverageinhealthinothercountries;ananalysisofthecurrentpolicyenvironmentandpoliticaleconomyforreform;andtheensuingkeyinstitutional,legislative,andpolicyopportunitiesandbottlenecks;studytourstotheRepublicofSerbiaandtheUnitedKingdom(UK)byRSandtheFBiH1respectively;andkeyinformantinterviewsaswellasconsultationswithvariouskeystakeholders.TheproposedP4Pdesignfeaturesleverageidentifiedstrategicopportunitiesandaddressoperationalchallenges.Informedbytheaboveandconsideringbehavioraleconomicsinsightsandpoliticaleconomyfactors,theapproachpresentedinthisreportidentifiesasetofkeylevers,bindingconstraints,andoperationalchallengesthatcanaffectthecapacityoftheentitiestoimplementpaymentincentivesforimprovedqualityofNCDcare.Recognizingthese,thereportrecommendsasetofstrategicdesignfeaturesandpolicyreforminitiativesfocusedonintroducing,strengthening,andinstitutionalizingtheP4Pmechanism.Drawingontheeconomicsofcontracts,italsorecognizestheimportanceofpoliticaleconomyissuesandproposestailoredtechnicalassistanceneedstostrengthencapacityforadaptation,adoption,andimplementation.Therefore,thecorrespondingimplicationsfortheproposeddesignfeaturesincludethefollowing: Changesinthepaymentmixshouldcontributetotacklingchallengesinthehealthsystems. Thecomplexadministrativeandhealthsystemsstructureimpliesthatpaymentreformsshouldbetailoredattheentityandcantonallevels(fortheFBiH). TheprimarypurchaserwillplayasignificantroleintheimplementationofP4P.Theroleofserviceusersshouldshiftfrompassiveconsumptiontoactiveengagement.1.inkingpaymentincentivestoperformanceiskeyforimpactonaccesstoandqualityofNCDcare.Toexplicitlylinkpaymentincentivestoperformance,theproposeddesignfeaturesspanthefollowingkeydimensions:performancemeasures,basisofpayment,paymentattributes,recipientofpayment,andtargetedoutcomes.Qualityofcare(QoC)istheperformancemeasure,spanningstructure,process,andoutcomemeasures.Forcost-effectiveimplementationandtoinstitutionalizeP4P,indicatorsofQoCW川bedrawnfromexistingsystemstheAgencyforCertification,Accreditation,andHealthCareQualityImprovementoftheRSandtheAgencyforAccreditationandQualityinHealthoftheFBiHanddifferbyservicedeliverylevel.ThiswillhappenundertheHSIPasperthelegalagreement.Asabasisforpayment,aformula-basedcontinuousthresholdmethodologyandanappropriatequalitativerisk-adjustmentapproachisproposedtoincentivizecontinuousperformanceimprovementbyrewardingeachactivityundertaken.Regardingpaymentattributes,tostimulatelargerbehavioralresponses,bonuseswillbegivenandlinkedtoperformanceagainsttheselectedindicators.Giventhelowlevelsofproviderremuneration,nopenaltieswillbeimposed.Regardingrecipientofpayment,theincentivepaymentswillbedirectedtowardhealthprofessionalsinfamilymedicineteams.Finally,improvedpreventionandcontrolofNCDsisthetargetedoutcome.AnenablingenvironmentisanecessaryconditionforeffectiveP4Pimplementation.InlinewiththeagreementtoundertaketheproposedproviderpaymentreformthroughtheHSIPoperation,itisdesignedtobeimplementedinphasesovertheperiod2023to2026.Startingasapilot,reformwilleventuallybescaleduptocompletelycovertherespectiveentities,usingdatafrommonitoringthepilotstoinformchangestotheprograms.Thereportcallsforanenablingenvironmenttowardrobustdatasystems,meaningfulstakeholderengagement,adaptedlegalandregulatoryframework,andappropriateinstitutionalarrangements.Here,themainelementsofaneffectiveP4Pinterventioncouldincludeadaptingthelegalframework,buildingsupportfromprofessionalgroups,systematicstakeholderengagement,educationandtrainingoffacilitymanagers,(further)developmentofP4Pmethodology,establishingworkingandcoordinationcommittees,andallocatingsufficientbudgetaryandfinancialresources.FullyleveragingP4Pforimprovedhealthsystemsperformancewillrequiretargetedhigh-qualitytechnicalsupport.TosupportrolloutofP4PinRSandtheFBiH,thereportdetailstechnicalassistanceneeds.Thesemayincludedraftingthelegalandregulatoryframeworkchanges;developingtheP4Pmethodology;costingtheimplementationofP4P;advisingonthedesignofincentives,adjustments,andotherelements;designingthetrainingcurriculumforfacilitymanagersandotherstakeholders;andadaptingtheelectronichealthrecords(EHR)module.Thesehavebudgetaryimplications,withsupportenvisagedtobeprovidedundertheHSIP,theWorldBankMulti-DonorTrustFund(MDTF),andviatheannualbudgetsoftheMinistryofHealthandSocialWelfare(MoHSW)andtheMinistryofHealth(MoH)ofRSandtheFBiH1respectively.Thispaperisapreliminarystudythat,undertheMDTF5willbefollowedwithdevelopingformalinputstosupportthechangesunderHSIP,withtheinputssubmittedtotheMinistryofFinanceofBiH1entity-levelMoHs5andtheHealthInsuranceFund(HIF).Finally,comparedwithbusinessasusual,P4PimplementationintheRSandtheFBiHisenvisagedtonotonlyimprovethecoverageofNCDcarebutalsotheQoCprovided.Thiswillimprovehealthoutcomesandoverallhealthsystems'performance.I.IntroductionThisreportpresentsanapproachtoimplementingpaymentincentivesforimprovedqualityofservicedeliveryinRepublikaSrpska(RS)andtheFederationofBosniaandHerzegovina(FBiH).Basedonextensivestakeholderconsultations,synthesisoftheliteratureonpay-for-performance(P4P)mechanisms,andstudytourstolearnfromcountrieswithestablishedP4Psystems, The RS to the Republic of Serbia and the FBiH to the United Kingdom.thisdocumentwasdevelopedwithinthentextoftheFunctionalReviewofHealthSystems*PerformanceProgram(P167607)bytheWorldBankGroup(WBG).Itservesasaninitialframeworkfortheentity-levelmethodologicaldocumentstobeproducedundertheHealthSystemsImprovementProject(HSIPP171150)andtheWorldBank,sMulti-DonorTrustFund(MDTF)forHealthSystemsReform.ItsdevelopmentprocessinvolvedrepresentativesoftheMinistryofHealthandSocialWelfare(MoHSW)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