1. Session 11: Developing your Plan of Action Bruno Meessen ITM, Antwerp The World Bank June 2008

2. Overview Succeeding a RBF reform: some thoughts based on: Field experience in Rwanda (RBF) and Cambodia (HEF). Readings on policy reform (theory and experience). Rem: bottom-up experiences; a foreigner perspective; from ‘project funding’ to ‘budget support + project funding’. There are other set-ups. Six requirements for succeeding with RBF + personal observations. Instructions for the session.

3. Requirement # 1: RBF responds to a need! Performance of the health system is not satisfactory. Classical strategies have shown limits. RBF can address the problems. RBF is feasible.

4. Problem identification: some observations A good context and problem analysis helps. Brainstorm and involve relevant expertise. RBF is not a magic bullet; it does not replace more classical strategies; it completes them. Tackle first ‘easy’ problems (e.g. first line health services). This will ensure early results with your RBF and build political support for next stages. Think ‘health system’.

5. Requirement # 2: the champions Social entrepreneurs, the ‘engine’, the ‘path breakers’... Profile: They value strongly a significant change for the population. They have the institutional capacity to take risks, including to develop a pilot project. They are at the right place. They are ready to commit extensive part of their resources (time, finance…), for at least 2-3 years. They have the technical abilities to design, plan and explain the RBF strategy. They have some experience in health system and health care financing (ability to grasp issues from bottom to top level). They have political skills and a network.

6. The champions: some observations It will be a group of individuals representing a coalition of actors. In Cambodia: an international + national NGO (with early involvement and approval from a key MoH expert). In Rwanda: international NGOs, public health managers, visiting experts, the World Bank… Challenge to manage: some individuals may identify too much with the strategy (“their baby”) or want absolutely to bring their own ‘touch’; this creates risks for later stage (see below).

7. Requirement # 3: knowledge Knowledge will be key to success. Champions need a clear understanding how strategic knowledge is and adopt the appropriate attitude with this respect. Two kinds of knowledge: (1) evidence that the RBF ‘works’; (2) practical methods.

8. Observations on knowledge Early stage: tap existing expertise (consultants, a few agencies experienced with RBF). Read! An option: learning by doing through pilot projects. They allow to identify at early stage and without much political risks, constraints and opportunities in the local context. RBF is an evolving process: strong monitoring and evaluation is needed (what works / what needs to be changed) Use evidence to consolidate political support.

9. Requirement # 4: political support RBF corresponds in fact to a redistribution of property rights; some are potential winners, other are potential losers. People fear change. Information sessions before introducing changes! Explain the rationale, highlight the gains, answers to questions. Health staff: they may accept remuneration according to performance, but on average, they must win from the new scheme. Evidence is key to gain support for moving from pilot to national policy. If adopted at national level, RBF is a major reform with many effects (public administration, fiscal rules…). A reform requires support from key stakeholders.

10. Observations on political support Stakeholders that were supportive in Rwanda: the Ministry of Finance, Gvt, the World Bank, the path-breakers (international NGOs, but also health managers, the health staff, local authorities, …). Other aid agencies: many were busy with their projects, quite passive in fact (but informed and attentive!). Stakeholders that were supportive in Cambodia (yet, with different views on implementation strategies): the hospital staff, the MoH, the international NGOs, the local NGOs, donors, the health civil society platform, the World Bank… Remark: population and the poor are quite voiceless. Things that matter for gaining political reform: The general context (civil service, health labour market…). The content of the reform (identify what is acceptable and what is not). Its sequence and scope  the several tiers of the health system are a challenge. Its speed: big bang versus incrementalism.

11. Requirement # 5: national coordination As the RBF dynamic unfolds, there is a growing need for national coordination. Two stages: The projects. The health sector reform.

12. The project stage: some observations The easy period! Coordination can be loose; leave range of manoeuvre to actors at decentralised level. Main role for the coordination body: Encourage initiatives and experiments. Accumulate knowledge about experiments (visits, meetings, informal exchanges with different stakeholders…). Require projects to document their results. Gather instruments, specimen of contracts… Favour atmosphere of exchange of experiences (workshops…).

13. The health sector reform stage: some observations The difficult period! Establish a task-force / coordination body. Involve actors with field experience with RBF (incl. projects); Expertise: public health, health economics, law, health information system… Task-force leader: ideally, a MoH senior official full-time committed to the reform. Main role: Think “health sector reform” and not projects and experiments anymore. Harmonise, reach consensus, get commitment. Produce legal support (decree…). Plan (information to stakeholders, training…), steer, allocate resources. Oversee the HSR, monitor it. Commission evaluation. Disseminate results and lessons learned. Advocacy. …

14. The health sector reform stage: some observations Organisation of the task-force: Prefer frequent meetings to long documents. Delegate work packages to task-force members. Challenges: Actors follow different logics and frameworks. Not always easy to get people involved in a project to get committed to the national strategy. If there have been several pilots, harmonisation may create tensions (everybody wants its ‘model’ to be the national policy). Try to value lessons from every experience; develop a policy which is robust.

15. Requirement # 6: formalise and enforce new institutional arrangements Formalise the new arrangements = a process + formal contracts / documents. Enforce contracts. Create new stakeholders.

16. A few observations Project arrangements are very flexible: RBF is quite easy to implement in this set-up (TA available). Budget support = public finance +  rules are more stringent (e.g. MTEF, bidding must go through the national tender board, public audits). Many actors are not familiar with these constraints. Cambodia/Rwanda: formalisation (policy/decree) came after a few years of experience. Crucial to monitor results that are purchased and take sanctions if necessary (credibility!) Create stakeholders that will support RBF and fight reversal.

17. Group work: your Action Plan (1) 1. Do you have enough information to identify the problems, the best strategy and the right arrangements? (list possible sources of information and ways to move quickly) 2.Who will be your champions? (identify them and their possible contribution, if necessary how to create them) 3.How will you tap existing knowledge and generate new knowledge? (identify knowledge gaps and strategies to address them) at immediate actions will you take when you return home? What key people need to be briefed? Will you need to assess feasibility of implementing RBF by identifying weaknesses in existing systems and strategies to fill them?

18. Group work: your Action Plan (2) 4.How will you generate political support? (identify potential winners/losers, political risks, strategies) 5.What platform & resources for coordination (consider different stages, if any)? 6.Formalisation (policy): at which stage?

19. Group work: your Action Plan (3) Summary: which immediate actions will you take when you return home? Your plan should list actions, determine who in your team is accountable for each, and set deadlines for each action.