|Be Thi Bach from the Thai Hoc community health centre in Nguyen Binh District, Cao Bang Province, visits a hypertensive patient at home. — Photo Luxembourg Development Agency
by Emily Petsko
HA NOI (VNS) — Health workers in impoverished, mountainous provinces in northern Viet Nam have been earning higher salaries from an experimental pay-for-performance model that aims to enhance the performance of community health centres (CHCs) and well-being of area residents.
The model, called performance-based financing (PBF), creates incentives for health workers in order to enhance the productivity, scope and quality of work at health facilities.
According to project managers, on average, employees of participating CHCs in the two northern provinces of Cao Bang and Bac Kan have been earning individual performance rewards that equate to between 14 to 25 per cent of their regular Government salaries.
Hong Thi Thuy, a midwife at Minh Tam CHC in Cao Bang, said it was difficult to make ends meet on her average income of VND15 million US$665) per quarter prior to the implementation of PBF.
"Since April 2014, under the PBF program I have felt encouragement to perform my tasks well and to earn the appreciation of patients and colleagues," she said. "Over the last three quarters, I have received a PBF reward of 7 million dong on average, which increases my earnings by 46 per cent per quarter."
The project in the two provinces has been supported by the Luxembourg Agency for Development Co-Operation (LuxDev) since April 2014. Similarly, the World Bank has been supporting a result-based financing (RBF) initiative in Nghe An Province since May 2013.
Dr Hong Van Hao, deputy director of Nghe An's Department of Health, said during an international conference in Ha Noi in October that PBF has yielded "very substantive and practical results" by increasing patient visits and improving staff attitudes.
Prior to the project, ethnic minority villagers from Cao Bang and Bac Kan often bypassed their CHCs and opted to receive treatment at larger district hospitals. In the process, they typically spent more time and money travelling the extra distance.
PBF, which provides financial incentives to employees for meeting goals in target areas, has helped attract new patients and established community outreach efforts by improving staff motivation.
Dr. Tatyana Makarova, a health financing expert of the LuxDev project in Cao Bang and Bac Kan, said PBF provides incentives not only to medical workers, but also to patients to motivate them to use a particular service.
In the two provinces, a pregnant woman who chooses to give birth at a qualified health facility receives a reward – a mother and baby kit. Dr. Makarova said the project aims to build trust by giving both mothers and health workers rewards for safe deliveries.
She said many pregnant women in the region forego early monitoring, even though international standards recommend that women start prenatal care no later than 13 weeks into their pregnancies. Health workers who start prenatal care early and continue pregnancy monitoring on a regular basis receive a cumulative bonus of VND250,000 for every pregnant woman served at the CHC.
Ninh Vi Que, of the Minh Tam Commune in Cao Bang, said she was satisfied with the health services she received when she gave birth, adding, "I also received a kit with many useful items for my baby and myself."
In addition to enhancing the safety of newborn deliveries in 36 CHCs, the project has also targeted three other performance areas including early and regular prenatal care, the effective management of hypertension and the overall increase in the utilisation of health services.
Prior to PBF being implemented, health workers were paid based on their time and seniority – a "good system" to promote access to health care, but one that does not necessarily spur productivity or improve the quality of work, Dr Makarova said.
"Basically, we can say that we see the change," she said.
Under the current model, there is no limit to how much employees can earn in rewards, she said.
While employees track their own work for each patient served in the four target areas, the CHC uses a threefold system to verify and crosscheck staff reports. Then, each employee's score is multiplied by his or her individual quality score, which is assessed independently on a quarterly basis. A higher score yields higher rewards.
According to a feedback report from the Minh Tam CHC of Cao Bang, staff reported in May that the workload had increased due to the PBF measures.
At the same time, they also reported feeling more organised and more motivated to work with patients, as well as more invested in promoting the health centre's services throughout the commune and villages.
The work is expected to continue next year by both provinces with the remaining funds from LuxDev. However, the project ends this month, and future plans to sustain the pay-for-performance model with domestic resources have been discussed by officials in Cao Bang and Bac Kan.
Dr. Be Thi Bach, deputy director of the Project Implementation Unit of Cao Bang, said the model is sustainable.
"I am lucky to know and participate in the implementation of this model, so in my opinion, it is totally feasible in Viet Nam," Dr. Bach said. — VNS