1. Learning from RBF Implementation Dinesh Nair Sr Health Specialist

2. Overview of Session Why do we need to “learn from RBF”? Pulling it all together: the conceptual framework Nigeria Case Study

3. Many opportunities to learn Concept Design Start-up Implement Comprehensive learning agenda

4. A broad approach to learn from RBF implementation Holistic conceptual framework which highlights:  the intermediate outcomes necessary to achieve results  the utility of a multidisciplinary lens  the need for broad methodological approaches

5. Conceptual Framework

6. A Conceptual Framework for PBF  What organizational and behavioral changes do you expect PBF to bring about?

12. Learning from RBF Implementation: Nigeria Experience

13. RBF in Nigeria combines the PBF at health centers and DLIs to state and local governments Results Based Financing Approach in Nigeria Federal Govt. $$ State Govt. Finance based on.. (Examples) Increase in services Budget execution Bonus payment DLI Local Govt. Health Centers Supervision HMIS reporting HR management Quantity of services delivered Quality scores of the services PBF $$

14. Coverage has been increasing significantly, but further improvement is required Coverage of health services in Pre-Pilot facilities in Adamawa state (%) Inst Deliveries Vaccination FP Significant improvement from very low baseline in all indicators The is a good contrast with low DHS 2013 results in the North East (institutional delivery 20%, vaccination 14%, FP 11%) However, the overall utilization is still 30-40%

15. Detailed look at the operational data revealed the large variations in performance across Health Centers Institutional Delivery in Adamawa, normalized by 100,000 population Before PBF, all health centers were equally at very low levels After the PBF, some facilities achieved 100% coverage while others struggle with limited improvement

16. This performance variation across health centers also exists in quality of care Quality Score (%) in pre-pilot health centers in Adamawa state The quality score overall improves even in low performers However, the difference between high and low performers increased from 23% to 30%

17. Nigeria team engaged with two qualitative studies 1. Demand-side barrier analysis 2. Case study on key determinants What are the barriers to service utilization in the PBF facilities? Transport, service fee, culture/perception/ information barriers Competition of alternatives Interview and focus group High and low performers Design demand-side interventions What differentiate the good and poor performers under the PBF scheme? Health center management Contextual factors Health systems factors (e.g., supervision) Interviews, document review, direct observations Best and poorest performers Devise appropriate support to poor performers Research question Areas to look into Approaches Potential use

18. Demand-side barrier analysis revealed priority issues Demand- Side Barriers Transport Cost Major Barriers Found through Qualitative Analysis Community/ Culture Transport Voucher Possible approaches Services Competition Availability Cost Predictability of cost Hospitals Traditional providers Community support Magnit ude Controlla bility High Med High VariesLow VariesMed High VariesMed Community transport team Maternal shelter CCT Predictable/discounted pricing (supply-side) N/A Incentives for referral to PHCs (supply-side) Community engagement (supply-side) Communication and community involvement Priority demand side intervention Culture

19. Case study on determinants suggests the importance of community engagement and OIC management Identified determinants and non-determinants (preliminary) Non-Determinants Level of staffing (best performers lack staff) Remoteness of facilities (best performers are very rural) Technical qualifications of OIC (many community health workers manage facilities well) Business planning (none use it effectively yet) Determinants Community engagement (e.g., involve and reward community leaders, daily visits, incentivize for use of facility) OIC’s management capacity (e.g., full staff involvement, improve staff environment using performance bonus, rigorous performance review)

20. Research findings will drive new demand-side interventions with additional financing Proposed Transport Voucher and Strengthening management capacities Implementation Arrangements Build demand side interventions to support Supply Side RBF interventions Improve Capacities Community engagement Management capacity building of health centers Technical training (e.g., IMCI) for quality improvement (QI) Transport Voucher ANC standard visit (1-4) Institutional delivery Postnatal consultation Vaccination of children Growth monitoring Referred services provided by hospitals

21. Key Lessons Learned RBF performance hinges on how well and quickly we can learn from implementation and improve our approaches Qualitative research can provide a powerful insights and evidence in devising effective approaches Identifying right research questions and clear plan to use the research results are required to make the qualitative research meaningful