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Results Based Financing RBF Health by alicejenny


									                                                  Presented at the Centers for Disease
                                                  Control and Prevention (CDC), 6/23/09

An Overview

Joseph F. Naimoli, Senior Health Specialist
The World Bank

Contributions from Amie Batson, Ruth Levine, Magnus Lindelow, and Rena Eichler
                                       Different definitions; common theme

      Results-based financing (RBF) ≈ Pay-for-performance (P4P)

Provision of payment for      Transfer of money or material goods conditional
the attainment of well-        on taking a measureable action or achieving a
    defined results           predetermined performance target (CGD, 2009)

                           RBF takes many forms…
        Payers                                            Payees
  Donor                                             Recipients of care
  Central government                                Health care providers
  Local government
  Private insurer
                                      $             Facilities / NGOs
                                                    Central government
                                                    Local governments
                                       Schemes vary by country


   Supply-side incentives         Increased utilization of MCH
                                   •3 ANC visits                        Improved
                                   •Institutional delivery             Maternal and
                                   •Complete immunization of           Child Health
                                   children under 1
   Demand-side incentives         •Post-partum care within 1
                                   week of birth

                                                          Cash payment to women

                                                          Increased $ resources for
   Often multiple                                         health service providers

    beneficiaries in a cascading
    scheme                                                Increased $ resources for
                                                          regional & district health
                             Underlying principles

   People are motivated by intrinsic forces
    (professional pride)

   People are motivated by extrinsic forces
    (money and recognition)

   If designed well, RBF can reinforce
    professional pride with money and
    recognition, without undermining intrinsic
      Two perspectives

                      Business as usual unlikely to achieve
                     Millennium Development Goals (MDGs)

On track    Insufficient   No progress



MDG4 progress in 68 priority countries

                                         Source: UNICEF, 2008
Frustration with traditional input-based approaches

                               Inputs necessary
                               but not sufficient!

                   CGD, 2009
                         Tool for strengthening health system s

Health system building
blocks, WHO, 2007
                                           Increasing recognition as promising
                                                   strategy for MDGs

Taskforce on Innovative Financing for Health Systems
Raising and Channeling Funds


  • Clearly link financing for health to defined outcomes and
  to measurable results in broader programmes as well as in
  projects, building on the specific experiences from
  performance-based funding and SWAps.

  • Further develop and scale up systems that effectively
  manage development results and provide the incentives for
  achieving health outcomes.

                             Working Group 2 report ,Final Draft , 3 June 2009
      Two perspectives

                     Ministry of Finance looking to link decision making to
                                       observable results


Transfers from federal to     Decision:
provinces (15) based on #     Devolution of federal budget to
of poor women, children       lower levels in the health system
enrolled in social            accelerated, in part, by successful
insurance program and         results
performance on key
output measures
                   Low uptake of services, especially among the poor

       Children Fully Immunized, by Poverty
           Quintiles, Selected Countries
                                         Date of DHS
  80                                     Burkina '03
% 60                                     Cameroon '04
                                         Mozambique '03
                                         Bangladesh '04
                                         Vietnam '02
   0                                     Colombia '05
          Q1       Q3        Q5
       (Poorest)          (Richest)

                                         Source: Yazbeck, 2009; Gwatkin, 2007
                   Low uptakes of services, especially among the poor

        Antenatal care (3 or more visits) by
       Poverty Quintiles, Selected Countries
                                         Date of DHS
  80                                     Burkina '03
% 60                                     Cameroon '04
                                         Mozambique '03
                                         Bangladesh '04
                                         Vietnam '02
   0                                     Morocco '03-04
          Q1       Q3         Q5
       (Poorest)           (Richest)

                                         Source: Yazbeck, 2009; Gwatkin, 2007
                                                      Quality concerns, even following traditional
                                                       performance-improvement interventions
                                                                        (training, follow-up and job aids)

                           Proportion of children managed correctly in
                           primary health care facilities in 2 Integrated
                          Management of Childhood Illness (IMCI) districts
                             and 2 non-IMCI districts, Tanzania, 1999
                          80                          75                 69
   % children correctly


                          60                                                               Comparison
                          40                                                               districts
                                                 23                24
                                 16                                                        IMCI districts
                                All children   Children with    Children with
                                                 priority       non-priority
                                                conditions       conditions

Source: Bryce J, et al., Improving quality and efficiency of facility-based child health care through Integrated Management of
Childhood Illness in Tanzania, Health Policy and Planning, 2005, i69-i76
Current incentive structure contributes to poor
                           Far-ranging experimentation with provider payment reforms


Source: Buying results? Contracting for health service delivery in developing countries, Loevinsohn B.
and Harding A., The Lancet, 2005, 366, 676-681
                       • Conditional cash transfers to increase service use (Mexico,
Recipients of care       Nicaragua, etc.)
                       • Voucher schemes for free or highly subsidized services
    (demand)           • Conditional cash payments (maternal health in India)

                       • Contracts for public, non-profit, and for-profit service providers
Providers/facilities     (Rwanda, Zambia)
                       • NGO service delivery contracts (Afghanistan, DRC, Haiti)
     (supply)          • Incentives for health workers for institutional deliveries (India)

 Inter- and Intra-     • Global health partnerships (GAVI ISS)
                       • Conditional loan buy-downs (Polio eradication)
  governmental         • Incentives for provincial governments to improve maternal and
    Transfers            child health (Argentina)
                                Institutional change

                 Results and

Scaling Up                      with other


                                                Numerous possible implementation hazards

RBF in principle…
                      Define           Set                        Measure               Reward or
 action or                                            Perform
                    indicators       targets                    performance              sanction

                                                                Gaming the system
    Effort in one,                                              Reliability, validity
                                 Too ambitious, too
 several areas may                                               of administrative
 result in neglect of                                                  data
                                                                Cost of independent
                                            Rules of game
       Beneficiaries must control        provision or demand            Too much $, too little
           behavior change
                                           Quantity trumps              Undermining intrinsic
            Too many, too few                 quality                       motivation

                                        Solid evidence on demand side

   Conditional Cash Transfers (CCTs) rigorously evaluated
   Bulk of evidence from Latin American and Caribbean
    countries; some encouraging evidence from Bangladesh,
   Effective in reducing poverty in the short term
   Substantial increases in use of health services, primarily
    preventive services
   Impact on outcomes mixed
   Typically require complementary supply-side actions
                                             Source: Fiszbein et al., 2009


                                        Limited, mixed evidence on supply side

   Supply side: generally weak designs
   Argentina: increased enrollment of poor,
    previously uninsured women and children
   Afghanistan and Cambodia: increases in
    immunization, prenatal visits, overall service
    use, equity gains
   Many confounding factors (increased financing,
    TA, feedback, supervision, training, etc.) make it
    difficult to isolate effect of “incentive”
                            Rwanda leading the way in sub-Saharan Africa

       Rwanda: performance bonus scheme
   Prospective, quasi-experimental design
   Effect of incentives was “isolated” from effect of
    additional resources
   Equal amount of resources without the incentives
    would not have achieved the same outcomes
   Improved child health outcomes: height for age,

                                 Source: Gertler, et al. , 2009
                          Rwanda leading the way in sub-Saharan Africa

   Less impact on demand-sensitive interventions (ANC)

   Rwanda now piloting community-based performance
    bonus to increase demand

   Government adopting culture of results – moving RBF
    to Education and other sectors

                                            Source: Gertler, et al. , 2009
                             Need to open the “black box “ of

   Little information on “why” demand and
    supply schemes succeed or fail

   Insufficient information on unintended

   Sound monitoring, documentation and
    evaluation of new initiatives will be critical
                          New initiatives:       New initiatives:
 Current initiatives
                           Multilaterals           Bilaterals
                       • World Bank Health    • Norway support to
• GAVI support           Results Innovation     Nigeria, Tanzania,
  through HSS            Trust Fund ($95m)      Ethiopia

• Global Fund          • EC ‘s “variable      • AusAid currently
  support                tranche” approach      considering
                         to budget support      options; funding
                         (Vietnam, Laos)        seed grants
• Evaluation needed

                                              • USAID providing
                                                technical support
                                                and training
   Eight grants linked to IDA credits to finance the national
    strategy (International Health Partnership + principles)
    with focus on MDGs 4 and 5

   Why linked to IDA credits?
       Integrates RBF into broader policy dialogue between MOF and MOH
       Engages Bank operational staff at country level and headquarters
       Embeds RBF into Bank support for HSS
       Potentially leverages additional IDA for health

   $95 million from Norway supports comprehensive
    design, implementation, monitoring and impact
   Country         Design   Start   End (approx.)
    Eritrea        2008      2009       2011
  D.R. Congo       2008     2009        2011
   Zambia          2008     2009        2011
   Rwanda                   2009        2012
 Afghanistan                2009        2013
    Benin                   2010      2012-13
Kyrgyz Republic    2009     2010      2012-13
    Ghana         2009-10   2011        2014
   Afghanistan: performance-based bonus payments to NGOs

   DR Congo: performance-based bonus payments to public facilities
    and health workers
   Eritrea: demand-side incentives to mothers and performance
    budgets to administrative levels
   Rwanda: performance-based contracting with community
    organizations to increase demand

   Zambia: performance-based bonuses to public facilities and district
                    A common M&E Framework for RBF

         Monitoring and Documentation                                 Impact Evaluation

         Inputs              Activities           Outputs           Outcomes

Resources (time,      Contracted work        Contractual          Improved           Maternal
people, money,       program activities     services used,       coverage of         mortality
 commodities,            executed           delivered and      population with       reduction
 etc.) mobilized                          reporting verified     high impact
                     Support activities                         interventions     Infant and child
 Health system         implemented        Regular, timely,                            mortality
    platform                                appropriate        Improved quality      Reduction
 strengthened           Innovative,          incentive             of care
     (policy,           improvised        payments made
  regulations,       solutions applied      or withheld        Health promoting
 HMIS, financial                                               behavior change
procedures, etc.)
RBF is appealing to governments
   Motivation and creativity to strengthen health
   Flexibility to engage all providers (public,
    private, NGO)
   Culture of results - replacing focus on inputs
   Facilitates targeting – at poorest, MDG 4/5
   Both demand and supply side matter – and must be

   RBF not panacea! – must be part of broader
    dialogue with Ministries of Health and Finance and
    linked to investments in health

   Still building evidence base but exciting potential
     Accelerate progress toward MDGs
     Implement Paris/Accra Principles – align with the
      International Health Partnership

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