Operational Lessons from RBF

H E A LT H R E S U LT S I N N O VAT I O N T R U S T F U N D

Learning from Implementation

Petra Vergeer & Hadia Samaha

The Why and How of Operational Lessons

•  Review of ongoing PBF operations suggests some useful lessons

•  Focusing on the most important lessons will facilitate enhanced design and implementation

2

Lesson “Math-Phobes of the World Unite!”

– Use your data

•  Data is vital but under-utilized, despite a lot of effort invested into collecting, verifying and putting payment data on the web

17

Coverage of full vaccination among children under 1

0 10 20 30 40 50 60 70 80 90

100

4 1 2 3 4 1 2 3

Benin Burkina Faso Cameroon Kenya Nigeria Zambia Zimbabwe

%

Total quality score in health facilities

0

20

40

60

80

100

Burkina Faso

Benin Cameroon Kenya Nigeria Zambia Zimbabwe

%

Scores are averages of health centers and hospitals, technical and subjective where applicable Each bar represents a quarter of implementation

Internet applications with public front-end displaying performance & financial information

18

Burundi

Benin

Nigeria

3 services absorbing largest share of payment

7

OP >5 11%

OP <=5 15%

Inst. Delive

ries 17%

Others

57% Burundi

Zambia

Cameroon

Zimbabwe

OP contac

t 6% Inst.

Deliveries 35% FP

40%

Others 19%

OP contact

35%

Inst. Deliveri

es 15%

FP 21%

Others 29%

OPC 21%

Hosp. days 15%

VCT 12%

Others 52%

Figures reported are averages of all quarters to date

Strengthening work on administrative data 1.  Regularly monitoring program progress to identify candidates for

adjustment (indicators and tools) 2.  Taking advantage of HMIS data to compare with control facilities

and assess performance on non-incentivized services 3.  Developing online dashboard to facilitate use of data and

promote transparency 4.  Developing automated data analysis software to lessen burden

of data analysis for teams and encourage focus on results (ADEPT RBF)

8

Lesson “Keep moving the goalposts!”

Continuous Quality Improvement (CQI) implies Changing the Quality

Indicators

•  Many facilities make rapid improvements in quality and then plateau

6

At different levels: •  Facility Staff (managers, providers, staff -hospitals and clinics):

Need quality measures to assess and continuously improve services. Is care improving?

•  Regional/District & Program Managers: Need measures to assess and continuously strengthen essential system functions (e.g. competent workforce). Are essential system functions performing to standard?

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Understanding what different stakeholders want:   Clients (users of care)   National Policy-makers (value, policy)   Global Stakeholders (leadership, advocacy, accountability)

Integrating Quality into RBF Projects: Prioritizing Health Conditions/Services for Improvement

Consider phasing improvement priorities: “impossible to improve everything at once”

Involve local and international experts to: •  Review country standards against global evidence: evidence is constantly changing •  Distill standards into minimum “intervention bundles”: focus attention on essential

high-impact interventions •  Illustrative quality of care process measures based on minimum standards:

o  % cases adherent with standards – “all or nothing adherence” (e.g. % PPH cases managed per minimum standard; % cases pediatric pneumonia treated per standard)

o  Average % adherence with minimum standards (e.g. average % adherence with newborn sepsis case-management standards; N=30 cases)

Integrating Quality into RBF Projects: Selecting standards and Defining Quality of Care Measures

Illustrative quality measure: Quality of Partogram Completion (not so simple!)

Quality  Measure   Opera/onal  Defini/on  

   %  partograms  in  last  quarter  completed  per  standard  

      NUMERATOR:   Number   partograms  documen/ng   cervical   dila/on,  maternal   BP,  pulse,  temperature  at  admission  and  at  least  every  4  hours  un/l  delivery  

    DENOMINATOR:     Total   number   of  partograms  reviewed  

Lesson No commodities : No program

Worry about supply chains and drug availability !!!!!!

6

Improving Medicine supply chains to debottleneck RBF Programs

•  A useful first step is to diagnose the root causes of poor availability using an appropriate diagnostic tool. Poor quantification/requisitions, lack of transport, and procurement delays are common reasons.

•  Range of options for RBF programs to tackle these challenges. E.g., better requisitioning tools, contracted transport for obtaining supplies from district or regional stores, negotiated prices with private sector supply sources etc.

Lesson Seeing is Believing !!!!!

Verify and Counter Verify to Ensure You pay for real outputs !!!!

6

Factors influencing verification: A Conceptual Framework

Context  

Verifica/on  Characteris/cs  Impact  on  accuracy,  cost,  

sustainability  

RBF  Characteris/cs  RATIONALE  FOR  RBF  CONTRACT  TYPE  

USE  OF  RBF  RESULTS  

Improving  health  outcomes/HSS  RelaFonal  

Payment,  improving  performance    

Financial  accountability/Cost  control  Classic  

Transparency,  Naming  and  Shaming  

Monthly                          Annual  

Yes  Large  

Whole  universe                      Risk-­‐based  approach    Internal  

Verifica/on  Results  and  Their  Use  

FREQUENCY  

ALLOWABLE  ERROR  MARGIN  

SAMPLE  SIZE  INSTITUTIONAL  SETUP  ADVANCE  WARNING   No  

Small  

Third  party  

Learning,  Error  correcFon   Cost  recovery,  SancFon  

PAYMENT  FREQUENCY   Monthly   Annual  

POLITICAL  ENVIRONMENT   GOVERNANCE   CULTURE  

Key Recommendations Verification 1.  Consider context to determine whether merging

functions is appropriate (be mindful of conflict of interest)

2.  Analyze and use data available from verification and counter-verification

3.  Verification strategies should be dynamic, not static, and use a risk-based approach

Lesson Capable People Matter !!!!!

Invest in Your RBF Institutions & Teams

6

Scaling up capacity building and human resources for RBF and its sustainability

•  South-South TA with appropriate backstopping can lead to a successful home bred PBF pilot experience

•  Faculty members in Medical Schools are keen to embrace PBF, teach PBF and spread its principles and success stories, provided that they got the opportunity to be exposed to PBF in theory and in practice

•  Creating local contract management and verification capacity by selecting local non-governmental organizations and training and coaching them in PBF can be an attractive strategy in some countries.

•  Use of locals has made it possible to increase knowledge and capacity on RBF, research, and MNCH in-country. Ensure there is no bias and missing out on other international experiences

Lesson Let RBF Leave its Mark !!!

Think beyond tomorrow

6

RBF Institutional Set up and Ensuring Buy in

•  There are 3 main stages in the integration of RBF into a national health system

  Adoption: to move from PILOT to SCHEME   Institutional: to move from SCHEME to POLICY   PERPETUATION: to move from POLICY to SYSTEM

•  Key issues are in terms of: Actors, Resources (including $$$$), RBF design, and Process

•  Context shapes the trajectory