Using Results Based Financing to Strengthen Health Systems

RBF Team, World Bank Group

Content

• Overview of Results-Based Financing (RBF)

– About RBF: definition, diversity, intervention

• Supply Side RBF

– Inter Governmental – PBF at Facilities– Performance Based Contracting

• Demand Side Financing

– CCT/ Vouchers

• Design & Implementation Tips

2

Definition

• Results-Based Financing (RBF) is a cash payment or

nonmonetary transfer made to a national or sub-national

government, manager, provider, payer or consumer of

health services after predefined results have been attained

and verified.

• RBF is an umbrella term that encompasses various types

of interventions that target beneficiaries (for example,

conditional cash transfers), providers (for example,

performance-based financing), and country governments

(for example, cash on delivery, program for results).

3

Different Types of RBF

CCT/Vouchers

Payment based on FFS

Other monetary payments

Non-monetary rewards

Providers

Beneficiaries

Countries & Organizations

Incentives primarily for:

Type of Reward:

PBC

Afghanistan

COD/P4RNigeria, Ethiopia

OBA

BurkinaFaso, Gambia, Nigeria

PBFCommunity Primary

Secondary

Rwanda , Burundi“PRP”*

*Provider RecognitionPrograms

4

What is Results-Based Financing (RBF)?

• Demand-side incentive payments to individuals, households or communities, conditional on engaging in pre-agreed healthy behaviors or utilization of health services

• Supply-side incentive payments to facilities, teams of health workers conditional on increasing processes, health outputs or outcomes

• ‘Results-Based Financing (RBF) encompass the entire gamut of supply and demand side approaches

Why so much interest in RBF?

Disenchantment with traditional supply-side financing of inputs w/o accountability for outputs (a ‘sinkhole’ issue)

A way of motivating behavior change at household level by providing incentives conditional on households attending health education, clinics, or adopting preventive behaviors

Redirect attention of providers to making greater headway on priority diseases and health problems of the poor

Promising instrument(s) to more effectively target socially excluded and/or poorest households in remote areas,

Urgent scaling up of national performance to attain MDG 4 + 5 targets

Rapid Expansion of RBF

7

RBF & Inter Government Transfers

Plan Nacer in Argentina

8

Plan Nacer

• Health Insurance plan for:– Uninsured pregnant women (up to 45 days after birth) – Uninsured Children under 6– Target coverage of 2M women and children

• New strategy for health services provision:– Payments tied to performance– About 6% of health expenditures (2006 - NOA/NEA)

• Objectives:– Strengthen primary healthcare network– Increase accessibility and improve quality of health services– Reduce maternal and child mortality & morbidity

Argentina: Plan Nacer Intervention

Two Levels of Payments

1. Nation to Province

– Enrollment of eligible population– Targets for eligible population

• Outcomes: Birth weight & APGAR• Utilization: Prenatal care, well baby care, etc• Process and management

2. Province to public clinics

– Enroll public– Fee-for-service for 80 priority MCH services– Provider autonomy over use of funds

10

Plan Nacer’s Payment Mechanism

National Level

Provincial Level

Target Population

Providers

Result Based-Financing (RBF)

Fee for Service

Additional Budget: Staff incentives, equipment, etc

60% Enrollment

40% HealthOutcomes(Tracers)

Change in health outcomes

Health in Argentina

• Spike in Maternal and Infant mortality and morbidity following 2001 crisis, mostly amongst poor/uninsured

• Health coverage (2008)– Social Security (52%)– Private (10%)– Public Sector Budget (38%): uninsured

25.6

22.2

16.6 16.3 16.8 16.5

14.413.3 12.9

5

10

15

20

25

30

1990 1995 2000 2001 2002 2003 2004 2005 2006

Infa

nt

Mo

rtal

ity

rate

Evolution of infant mortality rates in Argentina Expressed as a rate per 1,000 live births

Argentina: Plan Nacer Results

• Provided 4.7 million pregnant women and children with health coverage

• Delivered 37 million maternal and child health services

– Reduced the probability of low birth weight by 23%– Reduced the probability of in-hospital neonatal death by

74 %

• Based on Plan Nacer’s success, the Government of Argentina has launched Program SUMAR

– SUMAR uses RBF mechanisms to expand health coverage to uninsured children and adolescents under 19 and to uninsured women between the ages of 20 and 64

13

Performance Based Financing

Community/ Health Facilities/ HospitalsRwanda, Burundi , Zambia, Zimbabwe

14

Inputs OutputsActivities

Traditional Financing

Results Based Financing

Rwanda: Increasing Coverage and Quality

17

Improving Efficiency in Zambia &

Zimbabwe

18

Performance Based ContractingAfghanistan

19

Performance based contracting

• A method of contracting where the results are defined rather than the process.o Includes measurementso Incentives

• Benefitso Better performance

• Results orientedo Better price

• Best and commercial practices and less mandated “how to’s” reduces costs

o Contractor has flexibility and incentive to be innovative• Contractor motivated to save money

The standards & measurement are

results orientedo quality of work

or producto quantity of work

or producto accessibilityo timeliness o accuracyo customer

satisfaction o not unduly

burdensome.

Performance indicators and standards

o Collect, track, and share data

o Conduct surveillance systemically

o Document resultso Review periodically and

jointly with the contractor• “Are we measuring the

right things

Demand Side FinancingVouchers in Bangladesh &

Pakistan

22

Bangladesh DSF program overview: incentives for both demand and supply side• Aims to rapidly increase utilization of maternal

health (MH) services via:– Vouchers for free antenatal (ANC), delivery, emergency

referral, and postnatal care (PNC), and laboratory tests.

– Cash transfers Tk. 2000 [$25] and gift bags if women deliver with skilled birth attendant at home or in facility, and transport stipend Tk. 500 [$ 6.25]. Emergency referral transport is also available.

– Cash incentives for providers/field workers for registering women and providing MH services

– “Seed fund” for facilities

23

24

Token for free consultation

ANC1 (%) of DSF vs National (BDHS)

0

49

59

76

87 88 89 91

4952 55

0

10

20

30

40

50

60

70

80

90

100

2004 2007 2008 2009 2010 2011 20122013 (upto july)

Ach

ieve

men

t P

erce

ntag

e (%

)

Year

ANC (DSF) ANC (BDH)

Source: DSF project office25

26

Assessing the Effects of RBF Approach

Zimbabwe: acute respiratory infection cases per 10,000 in RBF and non-RBF districts

Mar-11

May-11

Jul-11

Sep-11

Nov-11

Jan-12

Mar-12

May-12

Jul-12

Sep-12

Nov-12

0

50

100

150

200

250

300

350RBF districts non RBF districts

per 1

0,00

0 po

pula

tion

Program start

The trend in non-incentivized indicator appears similar between RBF and non-RBF districts, indicating no negative spill over

ANC in DSF Upazila vs Control Upazila

76

34

92

55

0

10

20

30

40

50

60

70

80

90

100

Had any ANC visit Had at least 3 ANC check-ups

%

Control Intervention

Source: Economic evaluation, 2010 27

Safe delivery (%) of DSF vs National (BDHS)

25

59

79

8784 85

82

1318

32

0

10

20

30

40

50

60

70

80

90

100

2004 2007 2008 2009 2010 2011 20122013 (upto july)

Per

cent

age

Year

Safe delivery(DSF) Safe delivery(BDHS)

Source: DSF project office28