World Bank presentation - International Health Partnership

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Transcript World Bank presentation - International Health Partnership

Using Results Based Financing to Strengthen Health Systems RBF Team, World Bank Group


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



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).


Different Types of RBF


Nigeria, Ethiopia Community Primary


Secondary Rwanda , Burundi




Incentives primarily for:

PRP”* Countries & Organizations Providers

Type of Reward:

Payment based on FFS


BurkinaFaso Gambia Other monetary payments , , Nigeria Non-monetary rewards Beneficiaries *Provider Recognition Programs 4

What is Results-Based Financing (RBF)?

Demand-side incentive payments to individuals, households or communities,


on engaging in pre-agreed healthy behaviors or utilization of health services

Supply-side incentive payments to facilities, teams of health workers


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


w/o accountability for outputs (a ‘sinkhole’ issue)

A way of motivating behavior change at household level

providing incentives conditional on households attending health education, clinics, or adopting preventive behaviors by

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

MDG 4 + 5 targets of national performance to attain

Rapid Expansion of RBF


RBF & Inter Government Transfers Plan Nacer in Argentina


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) •


– 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 • • •


: Birth weight & APGAR


: Prenatal care, well baby care, etc

Process and management


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 Result Based-Financing (RBF) Provincial Level Fee for Service 60% Enrollment 40% Health Outcomes (Tracers) Providers Additional Budget: Staff incentives, equipment, etc Target Population Change in health outcomes

Health in Argentina

Spike in Maternal and Infant mortality and morbidity following 2001 crisis, mostly amongst poor/uninsured Evolution of infant mortality rates in Argentina

Expressed as a rate per 1,000 live births

30 25.6

25 22.2

20 16.8





15 13.3



5 1990 1995 2000 2001 2002 Health coverage (2008)

– – – Social Security (52%) Private (10%) Public Sector Budget (38%): uninsured

2003 2004 2005 2006

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/ Hospitals Rwanda, Burundi , Zambia, Zimbabwe


Traditional Financing Inputs Activities Results Based Financing Outputs

Rwanda: Increasing Coverage and Quality


Improving Efficiency in Zambia & Zimbabwe 18

Performance Based Contracting Afghanistan


Performance based contracting

• A method of contracting where the results defined rather than the process .

o o Includes measurements Incentives are • Benefits o o o Better performance • Results oriented Better price • Best and commercial practices and less mandated “how to’s” reduces costs Contractor has flexibility and incentive to be innovative • Contractor motivated to save money

The standards & measurement are results oriented o o o o o o o quality of work or product quantity of work or product accessibility timeliness accuracy customer satisfaction not unduly burdensome.

Performance indicators and standards o o o o Collect, track, and share data Conduct surveillance systemically Document results Review periodically and jointly with the contractor • “Are we measuring the right things

Demand Side Financing Vouchers in Bangladesh & Pakistan


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 women and providing MH services for registering – “ Seed fund ” for facilities 23

Token for free consultation


ANC1 (%) of DSF vs National (BDHS)

ANC (DSF) ANC (BDH) 100 90 80 70 60 50 40 30 20 10 0 49 52

49 59 76 87 88


89 0

2004 2007 2008 2009 2010 2011 2012 Year Source: DSF project office



Assessing the Effects of RBF Approach

250 200 150 100 50 0 350

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

RBF districts non RBF districts Program start 300 The trend in non incentivized indicator appears similar between RBF and non-RBF districts, indicating no negative spill over 26

ANC in DSF Upazila vs Control Upazila



Intervention % 100 90 80 70 60 50 40 30 20 10 0

76 34 55

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

Source: Economic evaluation, 2010 27

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

Safe delivery(DSF) Safe delivery(BDHS) Source: DSF project office 40 30 20 10 0 100 90 80 70 60 50 13



59 79 87 84


85 82

2004 2007 2008 2009 Year 2010 2011 20122013 (upto july) 28