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

2. 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

3. 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

4. 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/P4R Nigeria, Ethiopia OBA BurkinaFaso, Gambia, Nigeria PBF CommunityPrimary Secondary Rwanda, Burundi “PRP”* *Provider Recognition Programs 4

5. 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

6. 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

7. Rapid Expansion of RBF 7

8. RBF & Inter Government Transfers Plan Nacer in Argentina 8

9. 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

10. 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

11. 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% Health Outcomes (Tracers) Change in health outcomes

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

13. 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

14. Performance Based Financing Community/ Health Facilities/ Hospitals Rwanda, Burundi, Zambia, Zimbabwe 14

15. Inputs Outputs Activities Traditional Financing Results Based Financing

17. Rwanda: Increasing Coverage and Quality 17

18. Improving Efficiency in Zambia & Zimbabwe 18

19. Performance Based Contracting Afghanistan 19

20. Performance based contracting A method of contracting where the results are defined rather than the process. o Includes measurements o Incentives Benefits o Better performance Results oriented o 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

21. The standards & measurement are results oriented o quality of work or product o quantity of work or product o accessibility o timeliness o accuracy o customer satisfaction o not unduly burdensome. Performance indicators and standards o Collect, track, and share data o Conduct surveillance systemically o Document results o Review periodically and jointly with the contractor “Are we measuring the right things

22. Demand Side Financing Vouchers in Bangladesh & Pakistan 22

23. 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. 24 Token for free consultation

25. ANC1 (%) of DSF vs National (BDHS) Source: DSF project office 25

26. Assessing the Effects of RBF Approach Zimbabwe: acute respiratory infection cases per 10,000 in RBF and non-RBF districts The trend in non- incentivized indicator appears similar between RBF and non-RBF districts, indicating no negative spill over 26

27. ANC in DSF Upazila vs Control Upazila Source: Economic evaluation, 2010 27

28. Safe delivery (%) of DSF vs National (BDHS) Source: DSF project office 28