an overview joseph f. naimoli, senior health specialist the world bank contributions from amie...
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An Overview
Joseph F. Naimoli, Senior Health SpecialistThe World Bank
Contributions from Amie Batson, Ruth Levine, Magnus Lindelow, and Rena Eichler
Presented at the Centers for DiseaseControl and Prevention (CDC), 6/23/09
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Results-based financing (RBF) ≈ Pay-for-performance (P4P)
Provision of payment for the
attainment of well-defined
results
Transfer of money or material goods conditional on taking a
measureable action or achieving a predetermined performance target
(CGD, 2009)
DonorCentral governmentLocal governmentPrivate insurer
$Recipients of careHealth care providersFacilities / NGOsCentral governmentLocal governments
RBF takes many forms…
Payers Payees
Different definitions; common theme
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Supply-side incentives
Demand-side incentives
Often multiple beneficiaries in a cascading scheme
Madagascar
Increased utilization of MCH services•3 ANC visits•Institutional delivery•Complete immunization of children under 1•Post-partum care within 1 week of birth
Improved Maternal and Child Health
Cash payment to women
Increased $ resources for health service
providers
Increased $ resources for
regional & district health authorities
Schemes vary by country
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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
Underlying principles
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RBF
Two perspectives
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Business as usual unlikely to achieve Millennium Development
Goals (MDGs)
MDG4 progress in 68 priority countries
Source: UNICEF, 2008
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Frustration with traditional input-based approaches
CGD, 2009
Inputs necessarybut not sufficient!
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Tool for strengthening health system s
Health system building blocks, WHO, 2007
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Increasing recognition as promising strategy for MDGs
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.
Taskforce on Innovative Financing for Health Systems Raising and Channeling Funds
Working Group 2 report ,Final Draft , 3 June 2009
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RBF
Two perspectives
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ARGENTINA: PLAN NACER
Ministry of Finance looking to link decision making to observable results
Transfers from federal to provinces (15) based on # of poor women, children enrolled in social insurance program and performance on key output measures
Decision:Devolution of federal budget to lower levels in the health systemaccelerated, in part, by successful results
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%
Low uptake of services, especially among the poor
Source: Yazbeck, 2009; Gwatkin, 2007
Date of DHS
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%
Low uptakes of services, especially among the poor
Source: Yazbeck, 2009; Gwatkin, 2007
Date of DHS
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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
Quality concerns, even following traditional performance-improvement interventions (training, follow-up and job aids)
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Current incentive structure contributes to poor performance
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RBF
Source: Buying results? Contracting for health service delivery in developing countries, Loevinsohn B. and Harding A., The Lancet, 2005, 366, 676-681
Far-ranging experimentation with provider payment reforms
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Institutional change
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Select action or output
Define indicato
rs
Set target
s
Perform
Measure performa
nce
RBF in principle…
But…Effort in one, several areas may result in
neglect of others
Too ambitious, too easy
Beneficiaries must control behavior
change
Too many, too few
Gaming the system
Reliability, validity of
administrative data
Cost of independent verificationToo much $, too
little
Undermining intrinsic
motivation
Rules of game
Unnecessary provision or
demand
Quantity trumps quality
Reward or
sanction
Numerous possible implementation hazards
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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
Solid evidence on demand side
Source: Fiszbein et al., 2009
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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”
Limited, mixed evidence on supply side
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Rwanda leading the way in sub-Saharan Africa
Source: Gertler, et al. , 2009
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
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Rwanda leading the way in sub-Saharan Africa
Source: Gertler, et al. , 2009
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
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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
Need to open the “black box “ of implementation
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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
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Country Start End (approx.)
Eritrea 2009 2011
D.R. Congo 2009 2011
Zambia 2009 2011
Rwanda 2009 2012
Afghanistan 2009 2013
Benin 2010 2012-13
Kyrgyz Republic 2010 2012-13
Ghana 2011 2014
Design
2008
2008
2008
2008
2008
2009
2009
2009-10
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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
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Inputs Activities Outputs Outcomes Long-run results
Improved coverage of population with high impact
interventions
Improved quality of care
Health promoting behavior change
Maternal mortalityreduction
Infant and child mortality
Reduction
Impact EvaluationMonitoring and Documentation
A common M&E Framework for RBF
Contractual services used, delivered and
reporting verified
Regular, timely,
appropriate incentive payments made or withheld
Contracted work program
activities executed
Support activities
implemented
Innovative, improvised solutions applied
Resources (time, people,
money, commodities,
etc.) mobilized
Health system platform
strengthened (policy,
regulations, HMIS, financial
procedures, etc.)
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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
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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