2 Jagaman district just erected a new health center and the health workers have started work. What are health workers doing? What motivates them?… why are mothers not getting the services they need?The HW are rushed so they decide to skip time-consuming activities like explaining good nutrition to a pregnant womanHW hasn’t been paid in 3 months and so is in a bad mood and is rude to the mothersHW doesn’t fill in the records – no one reads them anywayThe refrigerator breaks, the HW sends a message to his supervisor. He doesn’t hear anything back and the vaccines are spoiledThe health center runs out of some drugs and vaccines – the HW turns mothers away until her supervisors notes the stock out and sends more medicinesThe HW knows that 5 women in the community will be having babies soon but haven’t come back to the clinic for antenatal care in several months but they don’t have time to go to find them.2
3 What about mothers? Are they all coming to the facility and demanding services? Women in nearby communities know a new health clinic has been built but many women don’t go to the clinic because…They don’t have the bus fareWhat would the HWs do anyway for a pregnant woman? Is it really importantA friend went and said they had to wait 5 hours and when they finally saw the HW, the HW was rude, rushed her and told her to come back in 2 monthsShe went once and the HW said her child needed 2 vaccines but that they didn’t have them now and she needed to come backShe went and the HW told her she needed to eat special foods to keep her baby strong but she can’t afford those foods.The HWs charge extra fees to deliver your baby and she can’t afford them3
4 Would financial incentives and recognition motivate health workers to behave differently? Mary is a trained birth attendant. She cares about her community.Recently the government began providing the district with more funds but only if they can show that more women are using the facility to deliver their babies so….Mary organizes a special class for the all pregnant women in the community to explain the importance of eating well and getting antenatal careShe notices there is a stock out in drugs and vaccines. She calls her supervisor but he says he’ll send more drugs whenever the truck comes back – maybe in a week or so. She asks the local shop keeper who goes to the town every other day to stop at the town health clinic and pick up the supplies.been to the clinic in months. Mary asks other women from the same village to go check on them and encourage them to come back for a check up.Mary is proud of her work. More women are coming to the clinic now and they are thanking her for her help. After a long day, she takes the time to carefully fill in the forms to show how many women she has helped and how many babies she has delivered.4
5 Motivation and Flexibility People are motivated by internal forcesProfessional prideDesire to help othersAnd by external forcesMoneyRecognition such as awardsIf well designed, results-based financing reinforces the professional pride (internal motivation) with money and recognition (external motivation)Incentives matter - If a person has motivation and flexibility to overcome problems, major improvements can be achieved5
6 What is RBF?Cash or goods provided against measurable actions or achievement of a defined performance targetIncentives targeting the service provider’s behaviour to achieve results (individual, facilities or sub-national levels)Incentives targeting community, household and individual behavior to use servicesPAYORRECIPIENTHouseholdIndividualFacilitySub-nationalHealthResultsFinancial Incentives
7 Results-Based financing If designed well RBF can provides incentives to key actors to change behaviour and achieve health results.Increase use of services by overcoming financial, physical or information barriersStrengthen capacity to provide servicesMotivate health workersCatalyze changes that strengthen management.Improve information systems and use of information for decisionsImprove quality by rewarding correct diagnosis and treatmentImprove efficiency through better use of inputs to achieve health results7
8 RBF MechanismsThere are several mechanisms and ways to structure these mechanisms. There are even more names for each mechanism and it can be confusing. This workshop focuses on those mechanisms using incentives to change behaviorPay for Performance (P4P)Performance-based Financing (PBF)Performance based Incentives (PBI)Output-based AidFee for ServicesVouchersConditional cash paymentsConditional cash transferPerformance-based Contracting
9 RBF MechanismsMany mechanism and names. This workshop focus on those using incentives to change behaviorPay for Performance (P4P)Performance-based Financing (PBF)Performance-based Incentives (PBI)Output-based AidFee for ServicesVouchersConditional cash paymentsConditional cash transferPerformance-based ContractingService provider paid a bonus if they achieve agreed targetService provider paid a fee for each service delivered (Rwanda)Voucher to consumer for free health services or packages of services. Provider paid when remits vouchers.Voucher to mother entitling them to cash or in-kind payment when utilize servicePayment to consumer conditional on using health serviceWelfare transfer to household conditional on use of social services (education, health)Legal agreement governing terms of payment
10 Results-based financing can be used at any level but it must trickle down to the point of contact between the provider and household to impact resultsDonorsNational GovernmentSub-nationalRegion/DistrictResults Based AidResults BasedBudgeting and FinancingResults Based FinancingCCP, CCT, RB bonusesProvidersHealth CentersHospitalsHouseholdsor Individuals
11 Design Elements RBFAgreed target group who will be motivated by incentives to increase supply or demand of agreed health interventionsAgreed indicators for desired actionAttendance at birth by skilled professional; full immunizationAgreed target for the indicatorPopulation-based vs. quantity vs. per outputAgreed type and level of reward for resultsBonus for health center for 10% increase in number of attended births;Cash to a mother if she delivers baby in a facilityAgreed means of measuring and verifying progressSelf-reportingInstitutional records confirmed by periodic random auditsFinancing system to assure timely provision of rewards11
12 Questions to consider What is your maternal and child health goal? What interventions should be ramped up? What is the problem now?Population not demanding the service?Service not provided?Quality of service is poor?Will incentives help fix the problem?Funds to families/mothers – nationwide or target poorest?Rewards to motivate more services or better quality services in public sector, NGOs, private sector?Incentives to both families and service providers?Could the selected incentives create a new and different problem?12
13 Questions to considerWhat systems are needed to implement RBF successfully?Does the regulatory framework require change?How will results be routinely monitored (HMIS?) and verified?How will rewards be paid out – fiduciary system?How will contracts be designed, written and awarded?In long run, how will the government and donors assess if the RBF scheme was successful? How will the government decide if it will continue funds going through this scheme?How will you show impact?How will you show cost-effectiveness?How will you show if it should be modified or expanded?
14 RBF is exciting because incentives are powerful. RBF requires careful design and implementationto achieve desired results.