Can You Have Good Quality of Care in an Incentive-Based System?

When I traveled to India as part of PAI’s QUEST project, this question was front and center in my mind. PAI was in India to work with our partner C3 examining the systemic influences on quality reproductive health care, specifically focusing on family planning for young people and post-partum family planning.

During a site visit to a district-level women’s hospital in Uttar Pradesh, we met a young woman who had just given birth to a beautiful baby girl. Speaking through a translator we learned this was her second child, and she was scheduled to receive an inter-uterine contraceptive device (IUCD) that afternoon.

In 2010, the Family Planning Division of the Ministry of Health and Family Welfare of India developed a reference manual on post-partum inter-uterine contraceptive device (PPIUCD) insertion to increase provider competence and client uptake of PPIUCDs. When thinking about effectiveness, ease of method use, and practicality, the immediate postpartum period is an excellent opportunity for a woman to begin using an IUCD. Clinical recommendations for PPIUCD insertion are within 48 hours after delivery, or four weeks post-delivery. Many women are not able to make a four-week post-delivery check-up, so the ability to insert a PPIUCD while a woman is still in the hospital or clinic is ideal.

While this is the ideal time from a medical perspective, what if it’s not what a woman wants? What if this woman has never been counseled on family planning methods before? She may not know other options available to her, and her first time hearing about an IUCD would be right after delivery. While an IUCD is one of the most effective postpartum methods available, she can also use methods such as lactational amenorrhea, sterilization, condoms, or progestin-only oral contraceptives. In addition to knowing all of the contraceptive options, wanting another child in the near future is also her right, and she deserves counseling on how to use these methods as part of her planned childbearing. However, out of the multiple options available, the healthcare provider only gets an incentive if the woman accepts one of two: PPIUCD or sterilization.

In Uttar Pradesh, the only family planning methods with specific incentives and targets attached to them are female sterilization, vasectomies, IUCDs, and PPIUCDs. In the Uttar Pradesh Programme Implementation Plan for 2015-2016 (PIP) providers are incentivized at Rupee 150 (about $2.25 USD) per PPIUCD insertion, with a target of 105,000 PPICUD insertions for the year. Having PPIUCDs incentivized at this level raises the question of how to provide quality services while meeting targets that are government mandated. As we have highlighted before, having targets for contraception does not give people a free choice in their contraceptive method and can lead to dangerous outcomes.

When speaking with the doctor at the health facility, he told us they had a 10 percent PPIUCD target rate. According to the PIP, other facilities have a 20 percent PPIUCD target, and extra incentives are given to counselors if they go above this target. While we don’t know the counseling that the young woman received after giving birth, if the facility has a target for PPIUCDs, it raises the question if this woman was given full information about all the methods available to her so she could make a more informed choice.

PIPs do not tell us the whole story of what is going on in facilities, but the family planning section does highlight which areas are getting more funding than others. Family planning counseling rooms have been approved for high caseload facilities—only where a counselor is already employed—and supervision and reviews for PPIUCD insertions were not funded. There are no funds available for IUCD removal, either through compensation or specific training, which can limit a woman’s ability to have an IUCD removed when she wants.

Policies, such as these, that promote targets and incentives and do not offer proper training or resource support compromise a provider’s ability to provide high-quality care. It is these kinds of policies that C3, and the other QUEST partners will be carefully examining over the next year in the hopes of addressing the systemic barriers to quality reproductive health care.