Transcript Contemplation on Recommendations

RBF: Concepts & Draft Design
What is RBF for health?
PURCHASER/
PAYER
Financial
Incentives
RECIPIENT
(PROVIDER/
PATIENT)
Health
Results
Results-based Financing for health is any program that rewards the delivery of one or more
health outputs or outcomes, through financial incentives, upon verification that the agreedupon result has actually been delivered.
Traditional Input Financing vs. Output
Financing: A Shift in Focus
INPUTS
(human
resources,
drugs,
equipment,
etc.)
PROCESS
(training,
protocols
and
guidelines,
financial
manageme
nt,
procureme
nt, etc.)
Line item budgeting,
input supply,
monitoring of inputs
and processes,
reporting of results
OUTPUTS
(health
service
utilization,
promotion
activities)
Monitoring and
paying for outputs,
increased leeway for
local decisionmaking, verification
of results
OUTCOMES
(maternal
and child
mortality,
nutritional
outcomes,
life
expectancy)
Monitoring of
outcomes, evidence
based decision
making to achieve
results
Broad principles of design
• Tanzania will approach RBF as part of broad systems reform,
not a project
• Part of Health Care Financing Strategy Development
• Objective is to strengthen overall system, not just to top-up
individual workers
• Provider empowerment and autonomy is essential
• This is not a scale-up of Pwani: We learn from all experiences
to develop informed and customized design
What results are we purchasing?
Principles
• Underutilized & poor performing indicators
• Management & HSS indicators to ensure results achieved
• Preventive services prioritized
RHMT & CHMT
1. Supervision
2. Supply availability
3. Reporting accuracy timeliness
Secondary Care Providers
1. Select services (to be explored)
2. Quality of care (management +
clinical)
Primary Care Providers
1. MCH, Nutrition, FP, Communicable diseases
2. Select NCDs (hypertension & diabetes)
3. Quality of care (both management + clinical)
What and how will we pay for
results?
• Fee-for-Service and/or coverage targets
• Quality of care will be included
• Penalty or reward still TBD
• Allocation of staff incentives vis-à-vis facility reinvestment
• Option 1: Formula to determine allocation
• Option 2: No formula, full autonomy of facility to decide
• Incentives should vary by performance of staff, by cadre
• Further analysis of overall level is needed
Next steps for determining what/how to pay:
• Decision on incentive mechanism: 1) fee-for-service 2)coverage
targets 3) both
• Should RHMT & CHMT be paid for results of health facilities?
• If yes, then further exploration on how to structure
• How to consider equity:
• Pay more for same indicator based on poverty, geography
• How to measure quality for clinical and non-clinical
• How to incorporate client satisfaction
• Projections to determine total budget for incentive levels
Institutional Set Up
Regulator
Verifier
(internal/3rd party):
Purchaser
Provider
Fund Holder
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Providers
• Establish and enforce minimum standards
•
Standards should ensure service readiness for all selected RBF services
• Include all public providers from the start
•
Public providers not meeting minimum standards will be given special
investment to make them service ready
• Include private and faith-based if they meet minimum standards,
and if there is service gap
• For HSS, explore RHMT, CHMT, DED, MSD, RAS
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Purchasing
• Centralized purchaser: PMO-RALG to act as purchaser with a PS for
health. Already, they act as purchaser for roads.
• Decentralized purchasing: Local level is closer to ground realities,
and can purchase more effectively
• Can Regional Administrative Secretary or Council take on purchaser role?
• Or RAS to purchase from regional hospital, Council to purchase from PHC,
council hospital, dispensary
• Long-term vision: NHIF may take over as purchaser once their
capacity is built
27
Verification
• Internal:
•
•
CHMT and RHMT.
Hospitals quality improvement teams going to facilities possible
• 3rd Party:
•
•
•
Control and Auditor General with Zonal involvement.
Private agency hired
Research Institutions (SPH, IHI, NIMRI)
• Community Verification
•
Mechanism still needs to be assessed
28
Fundholding
• Short-term:
• Ministry of Finance using its preferred bank (ie NMB)
• Development partners under MOHSW
• Long-term:
• Maintain short-term arrangements if working; look
for alternative options if not working
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Institutional Set Up
Consider possible conflicts of interest
Regulator
MOHSW
Verifier
Internal 3rd Party
Purchaser:
1. CHMT&RHMT
1. CAG
2. Hospital QI
teams
2. Private
1.PMORLG
2.RAS
3.NHIF
3. Research
institutions
Provider
1. Clinical: All public,
select private & FBO
2. HSS: RHMT, CHMT, DED
MSD, RAS
Fund Holder
1. DPs
2. MOF (preferred
bank)
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Relationship to Health Financing Strategy (HFS)
• Implementation of overarching HFS (including Health Insurance options)
will take time
• A key principle of HFS discussions is output-based financing
• RBF design and timing has significant opportunities to fulfilling the HFS:
• RBF could help incentivize the Min. Benefit Package being defined as
part of HFS, reinvigorate service agreement mechanisms etc.
• Lead the improvement in the health purchasing function at various
levels (e.g. LGA level) and for concrete results
• RBF would be one of the purchasing approaches guided by the HFS
What are the next steps?
•Establish and capacitate RBF coordinating and oversight body
•Finalize key technical design elements
• Capacity assessments
• Legal assessments
• Autonomy
•Engage in stakeholder consultation
• Separate consultation with key stakeholder groups such as basket fund partners, providers, regionals,
district
• Refine, validate and agree on final design
• TC-SWAP meeting
•Phasing and geographic phasing
• Develop objective selection criteria: Poverty, coverage
• Criteria for role-out to new regions
• Develop timeline for phasing
•Financing: Assess cost of options for phasing vis-à-vis available funding
•Implementation preparation
• Develop TA& training plan for implementation at all levels
•Continued linkages and revision as HCF strategy is developed
Take Home Messages
• General interest on output based/results based
financing
• P4P is not static but adapts to needs of health
system
• Intrinsic part of fulfilling new HCF system
• Health Systems Strengthening focused