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October 2013
Maternal, Newborn and Child Health
Working Paper
UNICEF Health Section, Program Division
unite for children
Performance-Based Equitable Resource
Allocation Model: The Punjab Experience
ii
Performance-Based Equitable Resource Allocation Model: The Punjab Experience ©United Nations Children’s Fund (UNICEF), New York, 2013
Knowledge Management and Implementation Research Unit, Health Section, Program Division
UNICEF
3 UN Plaza, New York, NY 10017
October 2013
This is a working document. It has been prepared to facilitate the exchange of knowledge and
to stimulate discussion. The findings, interpretations and conclusions expressed in this paper
are those of the authors and do not necessarily reflect the policies or views of UNICEF or of the
United Nations. The text is not edited to official publication standards, and UNICEF accepts no
responsibility for errors.
The designations in this publication do not imply an opinion on legal status of any country or
territory, or of its authorities, or the delimitation of frontiers.
The editors of the series are Theresa Diaz and Alyssa Sharkey of UNICEF Program Division. For
more information on the series, or to submit a working paper, please contact [email protected],
iii
Performance-Based Equitable Resource
Allocation Model The Punjab Experience
Afeef Mahmood, Katrina Estacio, Nuzhat Rafique, Thomas O’Connell
Keywords: health system strengthening, district-level, district health system strengthening,
performance, planning, financing, performance-based financing, performance-based planning,
resource allocation, equity, universal health coverage
Comments may be addressed by email to Afeef Mahmood: [email protected]
cc: [email protected], [email protected] and [email protected]
MATERNAL, NEWBORN AND CHILD HEALTH
WORKING PAPER
October 2013
iv
Acknowledgements
We thank Mr. Fawad Hassan (Secretary of Health, Punjab), Mr. Farasat Iqbal (Project Director
Punjab Health Sectors Reform Program, DoH Punjab), Dr. Anwer Janjua (Director Management
Information System, DoH Punjab), Rie Hiraoka (Senior Health Specialist, Asian Development
Bank), and Linda Arthur (Senior Social Sector Specialist, Asian Development Bank) for their
substantial contributions to the conception and development of the Punjab Resource Allocation
Model.
We also thank Alyssa Sharkey (Health Specialist, Knowledge Management and Implementation
Research Unit, UNICEF) and Julia Kim (Senior Health Advisor, Knowledge Management and
Implementation Research Unit, UNICEF) for their invaluable input in providing appropriate
revisions and comments. We thank Mary Beth Woodin for patiently editing various drafts, and
keeping excellent track of the numerous comments received.
v
Table of Contents
Acknowledgements .............................................................................................................. iv
Table of Contents .................................................................................................................. v
List of Acronyms ................................................................................................................... vi
Executive Summary ............................................................................................................. vii
Introduction .......................................................................................................................... 1
Punjab State Model for Resource Allocation .......................................................................... 5
Punjab Model: An Illustrative Example ............................................................................................9
Discussion ........................................................................................................................... 14
References .......................................................................................................................... 16
vi
List of Acronyms
ADB Asian Development Bank
DHSS District Health Systems Strengthening
GoPb Government of Punjab
HMIS Health Management Information System
HSRP Health Sector Reform Programme
LQAS Lot Quality Assurance Sampling
MDGs Millennium Development Goals
MoU Memorandum of Understanding
PBF Performance-Based Financing
PBP Performance-Based Planning
PMDGP Punjab Millennium Development Goals Program
UHC Universal Health Coverage
WHO World Health Organization
vii
Executive Summary
Achieving Universal Health Coverage (UHC) with equity requires addressing the needs of the
most marginalized and vulnerable populations within countries. Although many countries are
making progress towards the achievement of Millennium Development Goals (MDGs) 4 and 5,
intra- and inter-country inequities often persist. Moving forward, strategies need to focus on
reducing intra-country inequities if progress toward the MDGs is to accelerate and UHC is to be
achieved. One key challenge lies in the design and implementation of context-specific
performance−based financing strategies, at national and sub-national levels, that align with
performance−based planning.
This paper describes a performance−based model used in the Punjab province of Pakistan to
promote equity in access and use of services, and improve performance as a core tenet of
health planning and financing. The model was initially implemented in only a few Punjab
districts in 2010, and then was followed by provincial and national rollouts.
The goal of the “Performance−Based Equitable Resource Allocation Model” is to implement a
financial system capable of allocating resources to districts based on local needs, while
simultaneously rewarding them with additional resources for improvements in district health
performance. The model focuses on three objectives:
1. Provide a system−wide equitable resource allocation mechanism;
2. Allocate rewards for good performance while addressing equity and meeting essential local
resource requirements; and
3. Maintain transparency, accountability and predictability of resource allocation.
1
Introduction
Intra-country inequities hinder achievement of Millennium Development Goals and Universal
Health Coverage.
Achieving UHC with equity requires addressing the needs of the most marginalized and
vulnerable populations within countries. Though many developing countries are making progress
toward the Millennium Development Goals (MDGs), intra-country inequities persist, particularly
in those countries that are falling short on MDG 4: reduction in child mortality and MDG 5:
improvement in maternal health (UNICEF 2010b; Lozano, Wang et al. 2011). In 2008, more than
50% of all maternal deaths occurred in countries in Sub-Saharan Africa and South Asia (Hogan,
Foreman et al. 2010). An equity-focused approach has been proposed as a means to accelerate
progress towards MDG 4 and 5, and consequently prevent millions of maternal and child deaths
(UNICEF2010a). Looking ahead, policies should move beyond the MDGs to enable significant
reductions in intra-country, not just inter-country, inequities to achieve UHC (Gyorkos, Joseph et
al. 2009; UNICEF 2010b; Verguet, Jassat et al. 2012)
Health system strengthening is key to reducing inequities and improving health coverage,
particularly among the most marginalized populations.
WHO reports that overcoming health system weaknesses can lead to improvements in health
outcomes (WHO 2007). However, initial health system strengthening models, focused primarily
on reforming national strategies and lacked a clear linkage to operational strategies to improve
district and sub-district service delivery (Travis, Bennett et al. 2004). One major challenge is the
overreliance on national aggregated data to assess progress, rather than appropriately
disaggregated statistics to identify patterns of inequity linked to income, gender, geographic
location, and other important social determinants of health (Kim, Baum et al. 2011). Yet, granular
local data is considered necessary to assess root causes of poor performance and uncover
inequities at the district level (Marmot, Friel et al. 2008).
Resolving intra-country inequities requires coherence between pro-poor and other equity-based
planning and financing, including the concurrent creation of incentives to achieve UHC targets.
Such a strategy necessitates alignment of financing with planning at sub-national and national
levels, in order to reorient national health system strengthening and reforms towards achieving
UHC with equity.
Performance-based financing is one strategy used to support district level health system
strengthening.
There is a growing recognition that achieving equity-focused outcomes requires that
Performance-Based Financing (PBF) is consistent with Performance-Based Planning (PBP), that is
to say “linking burden with budget allocation” (Walley, Lawn et al. 2008). One approach is to use
District Health Systems Strengthening (DHSS) (Bucagu, Kagubare et al. 2012; Dynes, Buffington et
al. 2013; Liljestrand and Sambath 2012) as both a vehicle for delivering UHC, and as a way to craft
supply-side incentives that reward greater access to quality and effective services.
2
Finance strategies must align with evidence-based district plans in order to adequately fund
efforts to achieve UHC with equity.
There are only a few documented attempts to align planning and financing in districts. One
example, in Zambia, involved transferring control of expenditures to the district level and
instituting an allocation formula based on district population size, density, and hospital beds, to
disburse financial resources to districts (Bossert, Chitah et al. 2003). In Rwanda,
performance-based contracts prompted district health system changes that resulted in an
increase in service utilization, financial accessibility and motivation of health staff (Soeters,
Habineza et al. 2006). The challenge remains to design and implement context-specific PBF that
aligns with PBP well enough to enhance district health system performance and foster UHC with
equity.
Performance-based financing, in the context of a decentralized health system strengthening
approach, aims to simultaneously achieve greater equity and improve district health system
performance. Most of the literature concerning performance-based incentives focuses on
improving individual health provider’s performance, and only recently, publications have
addressed the impact of PBF on district level performance in low-resource settings, such as in
Rwanda (Rusa 2009; Meessen, Soucat et al. 2011) and Congo (Soeters, Peerenboom et al. 2011).
A resource allocation model that addresses both needs and performance has the potential to
incentivize districts to address equity gaps. This paper describes such a model, currently used in
the Punjab province of Pakistan, designed to bring equity and performance into the mainstream
of policy planning and financing. The intention of the model is to distribute heath sector funds
based on the needs of each district and to reward enhanced performance.
3
Brief overview of Punjab’s health system
In 2006, the Punjab provincial government of Pakistan initiated a Health Sector Reform
Programme (HSRP) to improve the quality and coverage of services at primary care facilities
towards achievement of the MDGs (Javed and Amin 2007; Government of Punjab 2009a). An
analysis of Punjab healthcare expenditures revealed a steady decline in the proportion of the
district budget allocated for health, from 14.49% (2002-2003) to 12.46% (2005-2006) (Mahmood
2009b). While the HSRP set the tone for policy and priority setting, addressing financial resource
constraints was not a primary focus of the reform.
In Pakistan, historically, the Federal Government is responsible for national health policy and
planning along with prioritizing primary and secondary health care interventions. In August 2001,
the Government announced a far-reaching Management and Organization Reform Agenda for
reconstructing state institutions through the establishment of a democratically elected system of
District Governments. This led to devolution of service delivery and health financing from the
provincial level to the districts. District health system financing is now managed directly by the
district assemblies. This reform proved difficult to implement as district-level governments
struggled to absorb both administrative and management responsibilities. Other challenges arose
due to budget limitations, varying priorities across sectors, political interference and a lack of
management expertise (Javed and Amin 2007). The 18th Constitutional Amendment Bill of
2010−2011 (Government of Pakistan 2010) further devolved health sector functions to provinces,
making them fully responsible for all aspects of healthcare system legislation, which were
previously under the Federal Government’s domain.
Planning by provincial and district health departments follows two distinct but poorly aligned
types of financing mechanisms: one for the annual operational budget (i.e., salaries, drugs,
supplies, diagnostics, and other operating expenditures), and another for capital development
(i.e., construction of new hospitals, increasing existing service provision capacities, and in some
cases, preventive vertical programs) (Mahmood 2009a).
In developing provincial health plans, equity is not always considered and the distribution of
social and health indicators among sub-groups and localities is poorly understood. Statistics used
for planning are commonly presented as means or aggregates at the provincial level. As a result,
it is challenging to develop health plans that target the specific needs of a district (Ghaffar, Kazi et
al. 2000).
In recent years, Punjab’s progress towards the achievement of MDGs 4 and 5 has been less than
satisfactory. In 2007 – 2008, for example, the under-five mortality rate was 111 per 1,000 live
births and the infant mortality rate was 77 per 1000 live births, far from the MDG target of 52 per
1000 and 48 per 1000 live births, respectively (Government of Punjab 2009). Similarly, in 2008,
Punjab had an estimated maternal mortality rate of 276 per 100,000 live births against the target
of 140 per 100,000 live births (Government of Pakistan 2005). Based on the rate of progress for
these indicators, it was questionable whether Punjab would attain the MDG targets, unless
health sector reforms were rigorously implemented (Sohani, Rafique et al. 2009).
4
The Government of Punjab (GoPb) had growing concern that the level of health sector funding
was insufficient (Mahmood 2009b). Roughly 70 to 80% of funding was spent on salaries, with only
20% remaining to fund supplies and operations (Mahmood 2009b). In an effort to measure the
financial resources required to improve coverage of high impact interventions and achieve MDGs
4 and 5, the GoPb defined a cost-effective set of minimum service delivery standards (Mahmood
2009b). And, at the GoPb’s request, a loan application was submitted to the Asian Development
Bank (ADB) in order to meet these newly defined delivery standards. Against this backdrop, the
GoPb and the ADB developed the “Punjab Millennium Development Goals Program” (PMDGP) to
improve Punjab’s health service delivery through effective policy−making, investments in health
system strengthening, and narrowing of financing gaps (Government of Punjab 2009b).
In the midst of the health sector reforms, the GoPb realized that 36 districts were limited in their
capacity to absorb new funds, in large part due to a budget allocation process that did not link
funding to specific health care needs of the population. As an example, districts with large
hospitals automatically receive higher budget allocations, regardless of occupancy levels.
Consequently, simply providing more financial resources did not ensure that coverage, and more
importantly equity of coverage, would improve. The traditional supply-side approach of allocating
the majority of funds based on a district’s population size was deemed unsuitable since equity or
performance are not taken into account; instead funding is based entirely on health facility
needs, including gaps in supplies, infrastructure and equipment. To address these limitations, the
Department of Health considered various options for allocating additional resources to the
Punjab districts.
After long deliberations, in 2010, the GoPb decided on an allocation mechanism that addresses
base needs and provides incentives with rewards for districts that achieve measureable results
toward attainment of UHC with equity. This innovative approach to financing district health
systems is termed the Performance−Based Equitable Resource Allocation Model. This is a
resource allocation model, that 1) recognizes that not all districts are at the same level of
achievement of health targets, 2) provides financial resources to ensure that basic infrastructure
and operational mechanisms are in place, and 3) rewards individual districts for health indicator
improvements, relative to baseline values, rather than focus solely on one target for all districts.
5
Year 1
Calculate Needs Index
Define Performance Indicators
Meet Minimum Conditions
Distribute Base Allocation
Monitor Performance
Year 2
Evaluate Year 1 Performance to Calculate Performance Allocation
Re-calculate Needs Index
Define Performance Indicators
Distribute Base Allocation & Performance Allocation
Monitor Performance
Punjab State Model for Resource Allocation
The overall concept of a “performance−based equitable resource allocation model” is to have a
financial reward system that allocates resources to districts based on local needs while
simultaneously rewarding them for improvements in district health performance. The model
focuses on three objectives:
1) Provide a method (formula-based) for state-wide equitable resource allocations to all
districts;
2) Allocate rewards to districts for good performance, while addressing equity and reflecting
local needs; and
3) Maintain transparency, accountability and predictability of resource allocation.
The Performance−Based Equitable
Resource Allocation Model used in
Punjab (referred to as the “Punjab
Model” in this paper) divides the
allocation of funds to each district into
Base Allocation and Performance
components (Figure 1).
In year one, the total amount of funds
for each district is determined through
the application of a “Needs Index”
(Table 1). For the first year, each
district receives the entire calculated
amount.
Figure 1. Punjab Model
6
The aim is to ensure districts are able to address high priority infrastructure gaps and operational
challenges. This system strengthening seeks to provide the foundation for accelerated progress in
future years.
In the second and subsequent years, the amount calculated for each district under the Needs
Index is divided into a Base Allocation, which comprises 70% of the total amount, and a
“Performance Allocation” which comprises the remaining 30% of the total amount. The amount
of the Performance Allocation that a given district receives (i.e. from 0% to 30%) is based on
progress achieved in the prior year toward predetermined key performance indicators.
To define the Needs Index, four attributes of the health system for each district are assessed and
given a weight by the State. The weights chosen reflect an equity dimension (social deprivation
and mortality) as well as factoring in unit costs (actual number of facilities and rural persons). The
weight determines the amount of funds distributed to a district and results in a more equitable
and needs-based allocation of funds across districts. For instance, changes in the number of
health facilities will have four times greater impact on the total funds a district receives than
changes in the maternal and child mortality index. The Needs Index was developed in response to
the previous system of distributing funds, which was not perceived as transparent or
needs-driven. How funds are distributed in Punjab using the Needs Index is illustrated in Table 1.
Table 1. Application of the Needs Index in Punjab State
Prior to receiving any funds from the state, districts are required to meet a set of minimum
conditions, including a signed Memorandum of Understanding between the Punjab State
government and district authorities. This sets clear district-specific targets that will be used in
assessing the performance allocations. Thus, from the first year, all districts are aware of the
indicators that will be used to evaluate their performance in the following years. These conditions
are summarized in Table 2.
Needs Index Attributes Proportion of funds allocated
Number of Health Facilities a 40 %
Social Deprivation Index b 25 %
Rural Population c 25 %
Maternal and Child Mortality Index d 10 %
a A greater number of health facilities within a district requires proportionally more funds to buy medicines,
purchase equipment and perform maintenance and repairs; assuming utilization rates are similar across
districts. b Specific indicators used to calculate the Social Deprivation Index include adult literacy, primary school
enrollment, breastfeeding practices, skilled birth attendance, modern contraceptive use, adequate water
and sanitation access. c The estimated rural population headcount in each district is used, rather that the percent of persons living
in rural areas. d District Maternal Mortality Rates and Under-Five Mortality Rates, though not weighted by district
population.
7
Table 2. Minimum conditions for transfer of funds to a district
In year two of implementation, the Punjab Model shifts from the initial 100% Base Allocation of
the first year, to a 70% Base Allocation and the opportunity to earn up to 30% based upon
performance. The Base Allocation, still calculated using the Needs Index, is reduced to 70% of the
total funds a district is eligible to receive, and the remaining 30% is disbursed based on the
Performance Allocation (Figure 2).
Figure 2. Punjab Model: Base and performance allocations
The Performance Allocation component is computed by measuring the district’s improvements
along pre-defined performance indicators, as specified in the MoU (Table 3). The indicators
should be defined with caution since they are used to measure progress and calculate the
amount of resources awarded. The intention of the performance-based component is to
incentivize districts to attain improved performance, regardless of baseline conditions. The model
recognizes the difficulty and expense for districts with higher baselines to move towards their
targets. As an example, it is easier to move from 20 to 40% coverage, than to move from 70 to
Minimum Conditions
1. Sign a Memorandum of Understanding (MoU) between provincial and district governments,
whereby agreeing to:
• Achieve standards or targets (as measured by performance indicators)
• Report on utilization of funds
• Report on key agreed upon outputs
2. Prepare a 3-year rolling plan with clearly defined areas for use of funding.
3. Update plans on a yearly basis.
a The design of these conditions can vary depending on the specific requirements of each health program
within a given district (e.g. immunization, HIV/AIDS, TB control, antenatal care, etc.)
Resource Pool
50 million
Base Allocation
100%
Performance Allocation
30%
(based on performance
Year 1
All funds distributed as Base Allocation
Year 2
Funds distributed as Base and
Performance Allocation
Base Allocation
70%
(based on Needs Index)
8
75% coverage (Hailu and Tsukada 2011). It is expected that the Performance Allocation for each
district will steadily increase over time, as key indicators improve.
Table 3. Performance Indicators
Performance Indicators
1. Proportion of pregnant women registered for antenatal care
2. Proportion of pregnant women receiving antenatal visits(s)
3. Proportion of women delivered by Skilled Birth Attendants
4. Proportion of women who delivered at a health facility
5. Proportion of fully immunized children between 18 and 30 months of age
6. Tetanus Toxoid II coverage in pregnant women
7. Population coverage by Community Midwives
8. Human Resources Index (availability of essential Maternal Neonatal and Child Health staff)
9. Drugs Index (availability of essential drugs at facilities)
10. Equipment Index (availability of essential Maternal Neonatal and Child Health related
equipment at facilities)
9
Punjab Model: An Illustrative Example
This section presents an illustrative example (using dummy data) of how to calculate Base and
Performance Allocations using the Punjab Model. In a given province 'Z', there are five districts:
A, B, C, D, and E. Government funds available for allocation to the districts over a 3-year period
are as follows:
Year 1 = $ 5 million
Year 2 = $ 7 million
Year 3 = $ 8 million
In order to distribute the funds equitably among the five districts, the government applies the
Punjab Model as described below.
Year 1: Disbursement of Funds via Base Allocation
First year funding is solely Base Allocation and each district’s allocation is computed in a three-
step process (Table 4 and Table 5).
Step 1 Define Needs Index attributes and assign each a percentage of the total funding (Needs
Index Allocations). (In this example, mortality is left out to simplify the calculations,
though in practice, maternal and child mortality also are used to calculate the Needs
Index)
Step 2 Calculate funding for each Needs Index attribute as follows:
Needs Index Funding = Total Province Annual Budget x Needs Index Allocation
Table 4. Steps 1 & 2: Needs Index Funding Calculations
Step 3 For every attribute, calculate the amount allocated for each district.
District Allocation (per attribute) = (District measure/Province Total) x Needs Index Funding
Total District Base Allocation = Sum of District Allocations for Each Attribute
The following example illustrates the calculations to determine the amount of funds allocated to
health facilities in District A (Table 5):
District Allocation for Health Facilities in A =
(20 district health facilities /62 province health facilities) x $1.75 = $0.56M
Total District A Base Allocation = $0.56 + $0.46 + $0.48 = $1.5M
Needs Index Attributes Needs Index Allocation Needs Index Funding
Number of health facilities 35 % $5M x 35 % = $1.75M
Social deprivation index 35 % $5M x 35 % = $1.75M
Rural population 30 % $5M x 33 % = $1.50M
10
In this example, District A receives a total of 1.5M apportioned as follows: $560,000 for health
facilities, $460,000 for Social Deprivation and $480,000 for Rural Population. Table 5 illustrates
calculations for all Needs Index attributes, for all districts. The Total Allocation column indicates
how the 5M total funds are dispersed as Base Allocations across the five districts in Year 1.
Table 5. Step 3: District-Level Base Allocation Calculations for Year One
* Millions
Year 2: Disbursement of Funds via Base and Performance Allocations
During the second year (and subsequent years) of implementation, districts receive funding from
both Base and Performance Allocations. For year 2 $7 million is available for distribution among
the five districts: in this instance, the government selects 85% ($5.95 million) to be transferred as
the Base Allocation, with the remaining 15% ($1.05 million) set as the Performance Allocation.
Base Allocations are determined exactly as described above. However, each district’s
Performance Allocation is computed using the following 3-step process.
Step 1 Determine allocation to district groups based on the percentage of Performance
Indicators improved (Table 6):
• Based on improvements in indicators, classify districts into groups according to
performance level.
• Compute Performance Allocation on a group basis, with higher performing districts
receiving higher allocations
• Determine Incentive Bonus for high performing group(s).
• Calculate Performance Allocation for each group by summing Incentive Bonus (if
applicable) and Group Proportion.
Computations are as follows:
Group Proportion = Number of Districts in Performance Group / Total Number of Districts
Group Share = (Group Proportion x Incentive Bonus) + Group Proportion
Group Performance Allocation = Group Share x Total Allocated for Performance in Province
District
Measure
District
Allocation
District
Measure
District
Allocation
District
Measure
District
Allocation
Total
Allocation*
District No. Health
Facilities
Health
Facilities*
Social
Deprivation
Social
Deprivation*
Rural
Population*
Rural
Population*
A 20 $0.56 60% $0.46 10 $0.48 $1.50
B 12 $0.34 30% $0.23 6 $0.29 $0.86
C 8 $0.23 70% $0.53 4 $0.19 $0.95
D 6 $0.17 50% $0.38 3 $0.15 $0.70
E 16 $0.45 20% $0.15 8 $0.39 $0.99
Province Total 62 $1.75 230% $1.75 31 $1.50 $5.00
11
Table 6. Performance Classification and Group Performance Allocations
*Millions
The following example illustrates application of the computations for the Very Good Performance
Group (Districts A and E).
Group Proportion = 2 Districts in Very Good Group / 5 Districts = 40%
Group Share = (40% Group Proportion x 20% Incentive Bonus) + 40% = 48%
Group Performance Allocation = 48% x 1.05M = $0.50
In this case, 48% of the funds allocated for performance in the province are awarded to the Very
Good districts (A and E), and the remaining 52% is distributed to the Good districts (B, C, D)
Step 2 Once the amount for each performance group is calculated, use the results to calculate
the proportionate share for each district within a performance group (Table 7).
Proportionate Share for District = End-line – Baseline / Sum of Differences within
Performance Group
Example District A: (60 End-line) – (40 Baseline) / 25 = 0.8 Proportionate Share District A
Table 7. Proportionate Share for Each District
Performance
Group
% of Indicators
Improved
Number of
Districts
Group
Proportion
Incentive
Bonus
Group
Share
Group Performance
Allocation*
Very Good 90% or more 2 (A, E) 40% 20% 48% $0.50
Good 61% - 89% 3 (B, C, D) 60% None 52% $0.55
Average 41% - 60% − − − −
Acceptable 31% - 40% − − − −
Poor 30% and less −
Total 5 districts 100% 100% $1.05
Performance Group
Baseline
Coverage*
End-line
Coverage* Difference Proportionate Share for District
Very Good
District A 40 60 20 0.8
District E 80 85 5 0.2
Sum of Differences within Performance Level Group 25
Good
District B 65 70 5 0.19
District C 30 50 20 0.74
District D 50 52 2 0.07
Sum of Differences within Performance Level Group 27
* In this simplified example, an average coverage rate is used. In practice, the difference between base and
end−line for each indicator would be used to determine the proportionate share of the performance allocation for
each district.
12
Steps 1 and 2 only take into account improvements in performance indicators, irrespective of
baseline conditions. As mentioned above, the model recognizes the difficulty for districts with
higher baselines to move towards their targets. To account for these challenges, a Scale-Based
Score was derived to assign weights depending on a district’s baseline values (Table 8). Steps 3
and 4 are included to adjust performance allocations to reflect differences in baseline conditions.
Table 8. Scale-Based Score
Baseline 1-10% 11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100%
Score (S) 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2
Step 3 Using the Scale-Based Score, compute the Composite Index and Performance Share for
each district (Table 9).
Composite Index (CI) = Proportionate Share for District + Scale-Based Score
Performance Share (%) = (District CI / Sum of CI for District Group) x 100
Performance Share ($M) = Performance Share x Group Performance Allocation
The following example illustrates the computations for District A, a Very Good district.
Composite Index (CI) = 0.80 + 1.4 = 2.20
District A Performance Share = (2.20 / 4.20) x 100 = 52%
District A Funding = 52% x $0.50 = $0.26M
Table 9. Composite Index and Performance Share
For this illustrative example, the total allocation (sum of base and performance allocation)
received by each district during Year 2 is shown in Table 10.
Performance Share
Classification
Proportionate
Share
Scale-Based
Score
Composite
Index © % $M
Very Good
District A 0.8 1.4 2.20 52% $0.26
District E 0.2 1.8 2.00 48% $0.24
Total 4.20 $0.50
Good
District B 0.19 1.7 1.89 34% $0.19
District C 0.74 1.3 2.04 37% $0.20
District D 0.07 1.5 1.57 29% $0.16
Total 5.50 $0.55
13
Table 10. Year 2 Allocation per District
District
Base Allocation, 85%
Performance
Allocation, 15%
Total Allocation
per District Health
Facilities
Social
Deprivation
Rural
Population Total
A $ 0.67 $ 0.54 $ 0.58 $ 1.79 $ 0.26 $ 2.05
B $ 0.40 $ 0.27 $ 0.35 $ 1.02 $ 0.19 $ 1.21
C $ 0.27 $ 0.63 $ 0.23 $ 1.13 $ 0.20 $ 1.33
D $ 0.20 $ 0.46 $ 0.17 $ 0.83 $ 0.16 $ 0.99
E $ 0.54 $ 0.18 $ 0.46 $ 1.18 $ 0.24 $ 1.42
Total $ 2.08 $ 2.08 $ 1.79 $ 5.95 $ 1.05 $ 7.00
14
Discussion
The Punjab Model can be studied by countries seeking to align Performance−Based Financing
(PBF) with Performance−Based Planning (PBP) at sub-national levels, in the context of using
district health system strengthening as a means for moving towards equitable UHC. The benefits
of the model arise from the distribution of financial resources through both Base and
Performance Allocations. The Base Allocation, as determined by the needs of a district, provides
an opportunity to address the district health system’s distinctive infrastructure, operational and
epidemiological issues. The Performance Allocation also takes into account each district’s unique
circumstances, rather than setting a uniform performance target. Using this approach, a district is
rewarded for improved performance, not simply on progress towards a fixed target. The model
acknowledges that each district is unique and progress toward national targets may occur at
different rates and with varying degrees of difficulty.
To obtain district level support and cooperation, adoption of the Punjab Model calls for a
transparent process and broad-based stakeholder engagement as illustrated in Figure 3. Such an
approach is highly participatory, allowing health managers and public sector administrators from
all districts to be involved from the outset. The core group agrees on the performance indicators,
financial allocation models, and implementation strategies.
Figure 3. Advocacy and Stakeholder Engagement
Develop Policy Advocacy
• Engage individuals from Finance, Planning and Health (or other relevant sectors) at national and
sub-national levels.
Form Technical Core Group
• Include national technical and financing experts
• Adapt the model to country's health system, infrastructure and district-specific needs
Organize Advocacy Workshops
• Include district teams and those implementing at sub-national levels
• Build district capacity and ensure buy-in on performance linked resource allocation
Define Performance Indicators
• Establish priority areas with district teams
• Identify baseline data, source and means of verification
Several measures are recommended to ensure sustainability following implementation:
• Government leadership and ownership at all levels
• Positive competitive environment that emphasizes rewarding progress over punishing poor
performance
• Supportive supervision
• Timely technical support
• Third party evaluation to assess appropriateness of model for local context
The focus on local context offers greater flexibility than typical PBF approaches, allowing for
implementation in districts with varying priorities and needs. The model facilitates the
15
development of appropriate and feasible indicators to track needs, equity, and performance. In
Punjab, indicators are derived from existing Health Management Information Systems (HMIS),
making data collection feasible and sufficiently accurate to trigger funding decisions. The HMIS
data is regularly validated through the Lot Quality Assurance Sampling (LQAS) technique. An
annual household survey (third party validation) is also conducted and used to validate the data.
Adoption of the Punjab Model can foster a broader policy perspective, shifting focus away from
individual healthcare provider performance to improvements in district health system
performance. Furthermore, while the model did not originally intend to promote competition
among districts, it developed organically as districts were eager to be classified as a “Very Good”
district, even though this designation did not guarantee an increase in a district’s performance
share. In the case of districts that fully reached their targets, achieving high ratings became a
non-monetary incentive to sustain high coverage levels.
The model also aims to institutionalize incentives to increase coverage and inclusion of the
unreached. With implementation of the Punjab Model, lower performing districts are unable to
obtain funding by way of Performance Allocations, while those able to improve coverage (or
sustain already high coverage) receive additional funding. In Punjab, this approach effectively
reduced the gap between resource needs and district funding, while improving outcomes by
ensuring all districts receive a minimum Base Allocation.
By linking PBF to PBP at the district level, the model ensures that financing reflects measurable
improvements in the level and equity of health outcomes. Additionally, it is both practical and
strategic to build on existing planning and financing systems to avoid parallel processes that will
likely lack sustainability (Hotchkiss, Diana et al. 2012).
A sustainable post-2015 development agenda requires that health system strengthening be
reoriented toward rewarding districts for health system performance that delivers UHC with
equity. Future iterations of the Punjab Model can include development indicators to monitor
multi-sectoral progress in other social welfare areas. Ensuring sub-national planning and
financing align and focus on equity can potentially serve as a catalyst for extending services to the
most marginalized and vulnerable populations.
16
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