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Results Based Financing RBF Health

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Results Based Financing RBF Health Powered By Docstoc
					                                                  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


                                                     Madagascar

   Supply-side incentives         Increased utilization of MCH
                                   services
                                   •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
                                                                 authorities
                             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
    motivation
      Two perspectives




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



On track    Insufficient   No progress



                           24%
38%




                           38%




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


  Recommendations:

  • 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




RBF
                     Ministry of Finance looking to link decision making to
                                       observable results




              ARGENTINA: PLAN NACER

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
 100
                                         Date of DHS
  80                                     Burkina '03
% 60                                     Cameroon '04
                                         Mozambique '03
  40
                                         Bangladesh '04
  20
                                         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
 100
                                         Date of DHS
  80                                     Burkina '03
% 60                                     Cameroon '04
                                         Mozambique '03
  40
                                         Bangladesh '04
  20
                                         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
                          100
                          80                          75                 69
   % children correctly




                                      65
         managed




                          60                                                               Comparison
                          40                                                               districts
                                                 23                24
                                 16                                                        IMCI districts
                          20
                           0
                                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
                 performance
                           Far-ranging experimentation with provider payment reforms




                             RBF

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
                  systems
                  thinking

                                Alignment
Scaling Up                      with other
                                 reforms

                 RBF
                                 Political
Sustainability
                               stewardship

                 Regulatory
                  change
                                                Numerous possible implementation hazards




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

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

                          RBF
                                  RBF
                                        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,
    Cambodia
   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
                            RBF


                      RBF

                                  RBF
                                        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,
    morbidity

                                 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
                                    implementation




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

   Insufficient information on unintended
    consequences

   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
    evaluation
   Country         Design   Start   End (approx.)
    Eritrea        2008      2009       2011
  D.R. Congo       2008     2009        2011
   Zambia          2008     2009        2011
   Rwanda                   2009        2012
                   2008
 Afghanistan                2009        2013
                   2008
    Benin                   2010      2012-13
                   2009
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



                                                                                       Long-run
         Inputs              Activities           Outputs           Outcomes
                                                                                        results




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
    systems
   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
    balanced

   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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