1. DAR ES SALAAM – TANZANIA, NOVEMBER 2015 RESULTS BASED FINANCING (RBF) EARLY IMPLEMENTATION RESULTS AND LESSONS LEARNT 1

2. MAP OF TANZANIA & IMPLEMENTING REGION 2

3. TAKE-HOME MESSAGES Incentives to staff do not work without fundamental health systems strengthening initiatives The purpose of this pilot in Kishapu is to modify the P4P design on an ongoing basis The specific details of the verification process needed to be embedded in the design from the start We under-estimated the: 1. Independence of the verifiers, 2. Existence of National RBF team with enough members, 3

4. WHERE ARE WE? More needs to be done to improve newborn survival 4

5. MATERNAL MORTALITY RATIO: A LONG WAY TO GO Maternal mortality has declined by 21% between 2004-05 and 2009-10 Concerted efforts are required to achieve the 2015 target 5

6. Pilot Description in Kishapu (Shinyanga) 6

7. RBF KISHAPU PILOT IMPLEMENTATION  9 Month pre-pilot, 4 Quarterly cycles (April- Dec 2015)  Funded by the World Bank  Selected on the basis of social and economic characteristics among the other councils in the region (Shinyanga) which was also selected based on the criteria among the other regions Goal: To inform the Scale up in the following Regions 7

8. BACKGROUND INFORMATION: SHINYANGA REGION  Shinyanga is one of the 30 regions of Tanzaniaregions  Selected due to poor health outcome and high poverty index  The region is divided into 6 councils  The population is projected at 1,534,808 (NBS 2012)  There are a total of 212 health care facilities, of which: - 156 (74%) are public, - 19 (9%) are FBOs, - 37 (17%) are Private.  Kishapu has 55 Health Facilities in total: 45 are public, 4 are FBOs and 6 are private.  Shinyanga has one Regional Hospital and only one District Hospital which is Kahama Town Council. 8

9. INSTITUTIONAL SET UP 9 9

10. Quantity & Quality indicators are Selected and Payment is based on Achievements  Quantity Indicators are counted and have no limitation,  The fees generated by quantity indicators is based on the level of discrepancies with verified and DHIS2 Reported data,  Achievement of 100% of the quality assessment receives a full payment. Data Verification  Data Verification is done quarterly by comparing existing data in DHIS2 and data found in the source of data of the similar indicators  The Verifier was RAS who identified the pool of verifiers in the region.  The RAS and RHMT are assessed by National level Team. 10 IMPLEMENTATION OF THE PILOT

11. SELECTED INDICATORS 19 Quantity Indicators for Health Centres & dispensaries, 18 Areas of Quality assessment of the Dispensaries & HCs, 26 Areas of Quality assessment of the District Hospital & Upgraded Health Centres, 3 Areas of assessment for the Verifier, 10 Areas of assessment of RHMT, 12 Areas of assessment of CHMT, 6 Indicators for MSD Zonal, 4 Indicators for MSD Central. 11

12. Routine verification  Supportive supervision from CHMT and RHMT includes verification of HMIS data entry and records  Spot check verification is also performed by the PMT Specific Verifications to be conducted  Regional Identified Team of Verifiers Composed by members from RAS, NHIF, RHMT and Health NGOs operating in the region perform internal Verification Quarterly  Independent verifier – Controller Auditor General (separately contracted) has a mandate to assume the function of counter verification twice a year but this activity has not yet been done.  Payments to the Providers is made through an independent fund holder – NHIF after the verification STRUCTURAL FEATURES OF THE PILOT Data collection and verification 12

13. FIRST VERIFICATION (Q. APRIL-JUNE )RESULTS RESULTS KAHAMA DH: 46.4%; RHMT: 82.4%; KISHAPU CHMT: 59.1% & RAS: 100%

14. READNESS ASSESSMENT DONE FOR NEXT COUNCILS IN SHINYANGA & MWANZA REGIONS – USING BRN INITIATIVE The assessment has been conducted by the Big Results Now (BRN) star rating team. Each facility had to undergo readiness assessment before being enrolled to the RBF system; The minimum readiness criterion is to have one star with adequate staffing (at least one skilled personnel at a dispensary level) but also the following elements are considered in the assessment tool: Communication means, Conducive infrastructures for provision of quality health care, Emergency transportation arrangement for referral, Power supply, Availability of running water; Waste management facilities. 14

15. THE RATING MECHANISM IS DEVISED BASED ON THE CURRENT SITUATION OF HEALTH FACILITIES IN GENERAL Major Features Characteristics of Facility at Each Rating Score on Assessment Tool No Star 0-19% 1 Star 20-39% 2 Star 40-59% 3 Star 60-79% 4 Star 80-89% 5 Star 90-100% Source(s): BRN Healthcare (2014) 15

16. RESULTS: KISHAPU COUNCIL 16 HEALTH FACILITY HF OWNERSHIP STARSTOTAL 0123 DISPENSARIESLGA 8 330 041 PRIVATE 05 00 5 FBO 0 40 0 4 HEALTH CENTERS LGA0 3 10 4 HOSPITALSPRIVATE 00 1 0 1 TOTAL 845 20 55 16

17. RESULTS: ALL COUNCILS IN SHINYANGA HEALTH FACILITY HF OWNERSHIP STARSTOTAL 0123 DISPENSARIESLGA 2510670138 PRIVATE 13181032 FBO 185115 MILITARY 11002 POLICE 01001 PRISON 01001 HEALTH CENTERS LGA 076013 PRIVATE 02103 FBO 02013 HOSPITALSLGA 00101 PRIVATE 01102 FBO 01001 TOTAL 40148222212 17

18. TIMELINE & SCALE UP PLAN 18

19. ISSUES AND CHALLENGES IDENTIFIED DURING IMPLEMENTATION  Inadequate infrastructures which made some facilities to score 0-star during readiness assessment,  Shortage of basic essential equipment and supplies needed to provide Reproductive and Child Health Services beyond health facility control,  Irregular Supportive Supervision by management teams,  Delays in paying 1 st Verification Payment,  Difficulties in direct incentive payment to the Health Facilities from the fund holder 19

20. LESSONS LEARNT  Essential equipment and supplies are not available at all times in the facilities,  RBF can only work if supportive supervision visits are regularly conducted at facilities,  Direct payment from the fund holder to the provider is very important to avoid delays and any other risks that may occur,  There is an opportunity for correcting the identified issues 20

21. WAY FORWARD  Ensure incentive funds planned for facility improvement is used to procure missing essential equipment and supplies,  Use lesson learnt from the pilot phase to ensure the scale up is done smoothly. 21

22. SUSTAINABILITY OF RBF AS ENVISIONED BY HEALTH CARE FINANCING STRATEGY SNHI Other vertical or parallel programs or funding Remainder of general revenue budget & HBF Portion of OC Budget AIDS Trust Fund Employer Contribution Employee Contribution GOT subsidy for poor and vulnerable Community Contribution (CHF) Reimbursement to Facilities Matching Payment to MBP Based on Core Output-Based Payment Systems, Performance (RBF) and Star Rating (BRN) 22

23. RBF IS EVIDENCE BASED & WE PAY WHAT WE SEE THANK YOU FOR YOUR ATTENTION