Transcript World Bank presentation - International Health Partnership
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
COD/P4R
Nigeria, Ethiopia Community Primary
PBF
Secondary Rwanda , Burundi
PBC
Afghanistan
OBA
“
Incentives primarily for:
PRP”* Countries & Organizations Providers
Type of Reward:
Payment based on FFS
CCT/Vouchers
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,
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
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
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RBF & Inter Government Transfers Plan Nacer in Argentina
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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 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
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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
16.6
16.3
16.5
14.4
15 13.3
12.9
10
•
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
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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
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Traditional Financing Inputs Activities Results Based Financing Outputs
Rwanda: Increasing Coverage and Quality
17
Improving Efficiency in Zambia & Zimbabwe 18
Performance Based Contracting Afghanistan
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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
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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
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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
55
89 0
2004 2007 2008 2009 2010 2011 2012 Year Source: DSF project office
91
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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
Control
92
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
25
18
59 79 87 84
32
85 82
2004 2007 2008 2009 Year 2010 2011 20122013 (upto july) 28